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· .FOR ,OFFICE USE ONi'~Y <br /> Received ,B.,y: __ . <br /> [,oniag Validation: <br /> <br />MARION COUNTY BUILDING INSPECTII~N <br />220 High Street NE <br /> Salem, OR 97301 <br /> 8:00 am - 4:30 pm Phone 58g-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />1. Location of Installation <br /> <br />2. Contractor Information <br /> <br />Pro y Owner Mailing Add~e.~s: Phone No. <br />Au'~fi. Agent/Lea~ee Mailing Address: Phone NO, <br />Co,lr~to~Business Name & Number Mailin~ Address: Phone No. <br />DEQ Licensed Contract~ & No. MailioS Address: Phone No. <br /> <br />DEq DEQ <br /> <br /> Comnte£¢ial (DSF-Dail SZ~_w_l~$e Flow) <br /> Site Evaluaton, first 1000 ~DS~F __ $ 2~.~ $20.~ $ <br /> Standard System less ~an 1~ gai. DSF 2~.~ 10.~ <br /> Stand~d System m~e [ha~ ~gM- DSF: <br /> Di~qai Trenches i~ S~mllm 2~,~ 10.~ <br />~ray Water W~te Dis~sal Sump 95.~ I0,~ <br /> Holdlng Tank 2~.~ 10.~ <br /> Pressme Dis~i~fion 280.~ 10.~ <br /> Sand Filter 355.~ 10-~ <br /> 'gle Dewatering System 280,~ I0.~ <br /> Plan Review <br /> (~0 ~al. DSE 1~1 gM. DSF <br /> (except SAND FILTEr) <br /> For each addMonal 5~ g~, DSF 20,~ <br /> Alterations 2~,~ 10.~ <br /> <br /> Consmc6on Penmt RenewM ~ield ~m) ' 120,~ 10.~ <br /> Coastmcaoa I ern~t Rea~w~ (No Fi*Id Vi~) 70.~ 10.~ <br />Esistin8 System Evaluation Re~ 120.~ 10,~ <br />Authorization Naice ~o Field Vj~ti) 70.~ 10,~ <br />Annual Evaluation of Almrnafive System 120.~ <br />_6~5}l,~?,~t~ua[ion,of ~$e System 75,~ 10.~ <br />~m~r Track Ins m~ion, First l~c~ ........... 50,~ <br />Pum~r Track Ing~ecfion, ea. ~dl. lmek 35.~ <br />Other <br /> <br />(Ma~k if Applicable to this Application) <br /> Tesl Hole~q axe Dug <br /> I will call when Test Hole,~ Dug <br /> <br /> I am performing wo~k on a propet~y I own or o¢copy <br /> i am a registered b~lder ~ ( ) ~e amhofi~d repr~enmfive <br /> of a tegt~ter*d b0ilder, <br /> The work will ~ ~fform~l by a DEQ I J~nsed Installer <br /> Other <br /> I agree to install steering to ~e submittM plans and <br /> s~ifications, the laws of the State & ~egon and the <br /> or~naac~ of Marion Couaty, <br /> <br />Residential Sin$1e Family <br />Site Evaluafion~ Fwst lot $ 200.00 $20.00 $ <br />Site Evaluation, ca. addI. lot 165.00 20,'0~ <br />GonsR'uctlon pern~t <br />Standard System 200.00 <br />Capping Fill 330.00 --10~00 <br />Disl:x~al Trench in Saprolite 200.00 10.00 <br />Gray Wamr Disp~ai Sump 95.00 10;0~ <br />Hoidlng Tank 200.00 10,00 <br />P~sur~ Disffibution 280.00 lO,0(J <br />Redundant 200.00 10.012 <br />Sand Filter 355100 'i'D'.l~ ' <br />Seepage Trench 200.00 10.00 <br />Steep Slope 200,00 lO.0~J <br />· rile Dewatering ~80,00 J0-(--~ <br />Alteration 200.00 10.0ti <br />RcI::Mr, Majm-~dr ai nfl e]~ 95.00 10,0~ <br />Repair~ Minor (tank) 60.00 I 0.(YOi <br />Construction Permit Renewal (Field Visit) i20.00 10.00 <br />Construction Permit Renewal (No Field Visit) 70,00 ,_.I.~O,O~ ............. <br />Reinspection Fee 25.00 .0~ <br />Amhori;',ation Nofice (Field Vi*it) 120,00 10.00 <br />Authorization N,:~ice (No field visit) 70.01 10,00 <br />Existing System Evaluation 120.00 10.0~ <br />Annaal Evaluation/Alternative System 120.00 ,0~ <br />Annual Evaluat,ion/Temp. or Hardsliip MH 75.00 .lB <br />Rural Area Vahan~ Site Evaluation 200AX) 20.00 <br /> <br />Total $ [ <br /> <br />Receipt No._ <br /> <br />SIGNATURE OF APPLICANT: <br /> <br />DATE: <br /> <br />MC 15-74 REV 1/92 <br /> <br /> <br />