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Salem, OR 97301 "' ,..,
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<br />8;00 am _ 4:30 pm l~aoa6 ~88-5147 L
<br /> Code-A-Phone 5gg-7904
<br /> Fax 5sg-794g
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<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />~, Loc~tlon of ImLallafio~
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<br />2. Contractor Information
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<br />ContractOr Busine'~'s Name & Number Mailinl~ Address: Phonn No,
<br />DEQ Licensed Contractct& No. Mailing Address; Phona No,
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<br />DEQ DgQ
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<br /> Comm;'iq)al (DSF-Daily'~9'wage Flow) , $1
<br /> Sile Evalu~fion~ ,first lOOO gal, DSF 20~,00 $~0,O0
<br />Site Evaluation, es, addl. 500gal. DSF I 60,00 20.o0/m
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<br />I Standard ~ystem less than IbO0, gal, DSF 20~,"00 I0,00
<br />$200,0~. $I 5/each ~ddl: 5o0 8al. DSF 'i0,00
<br />Cap!~ing Fill ~0.00 I0.00
<br />D~Sposal Trenches in SaDm, li,t,e 200,00 10.00
<br />Gray Wa~r W~$1,~ Disposal SumP 95.00 10,00 .. ,.,
<br />[ II01dihg Tank 200.00 10.00
<br />! Sand Filter ~55,00 10.00
<br />~ S0epageTreu¢!l, 200,00 10.00
<br />S~aep Slope 200.00 10.00
<br />600gal, DSF, 1~01 gal, DSF $0,00 ,IX)
<br />(oxcept SAND FILTERS)
<br />For each addit!ona! 500 gal, DSF 20.00 .00
<br />-~lietation~ 2c~,~ I0,00
<br />Repair Minor 60,00 10.O0
<br />Construction Pern~it Recewal (Fieid Visits} 120,00 I0.00
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<br />.....~xlstln~ Sy$texn Evaluatiola R~po~t ,~,~0,00 I0.00
<br />Authorization Notice (Field Visit), 120,00 !0.00
<br />AaflmrLr~ion No:me (No Fi~M Visit) 70.001 10,00
<br />'Annual Evaluation of Lat~ge S, Tstem 75.0( 10.00
<br />_.P~per Tw,~k II~s~ti. ou, Fkst txu~k 50.0( ,00
<br />Pumper ~uck Inps*¢tlon ea. attdl, track 35.0(
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<br />(Ma~k if Applicable to this Application)
<br />(~ %st Hol~ a~e Dug
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<br />i am per fctmlng work on a pro~rty I own or occupy
<br />Iatn a wgistared builder et ( ) the authorized representative
<br />of a registered builder.
<br />The work will be perI'orm~ti by a DEQ Li~nsed In~taIler
<br />O~het
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<br /> Resldepfial Single Family .......
<br /> ,,,Site Evaluation, fa'st lot $ 200.~ g20.00
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<br /> Site Evaluation, ea. addL lot 165.0~ 20.00
<br /> Construction permit
<br /> Standard System 200,~0:lb'.00
<br /> Capping Fill 330,0~ 10,00
<br />Disp~al Trench i'n Saprolita 200,00 10,0()
<br />Gray,Wa~r Disposal SumP 95~0~ ~0.00
<br />,Holding Tank 200,(~ 10,00
<br />Pressure Dk~trthu~i~ ..... :~g0,00
<br />Redundant 200,00 lO.O~
<br />Sand Filter 355.00 10,013
<br />Se~.ag'~ Trella, ll ..... 200.00 10.0(2
<br />Staep S!ope 200,1~ 10,00
<br />,,,Tile Dawatating ..... 280.00 10.00
<br />Alteration 200.00 10.O0
<br />Repair, M~ior (dra~ufial'd), ' ' 95,¢~ 16.00
<br />Repair. 'Minor (tank) (',0.0~ i0~
<br />Constmedon Permit Renowal (Field Visit) 120.00 10,00
<br />ConsLmction Permit Renewal (No Field Visit) 70,00 10.00
<br />Rainspechon Fee 25,00
<br />Auflmrk,.ati0a Notice (Field Visit) ,,, 120.00 1
<br />Authorization N~:aiee (No field visit) 70.00 10.00
<br />_E_:dsting system Evaluation 120.06 lO,00
<br />Aua~al Evaluatiaa/Alt~r aa:lYe S,/at~'~ ,, 120,O3
<br />Annual Evaluation/Temp. or Hatdsltip MH 75.00
<br />Rural Area Variance Site Evaluation 200.00 20,0~
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<br />Total
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<br /> APPLICANT (please print):
<br />SiGNATI)RE OF APPLIC~ANT:
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<br />MC 15-74 REV 1/92
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