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SITE EVALUATION AND/OR SEFFIC PERM~ APPLICATION
<br />L L~fion of I~l~fion
<br />
<br />Subdivision
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<br />2. Contractor Information
<br />
<br />Ptol'~rry Owner Mailing Addre4s: Phone No,
<br />Auth, AgenffLea~ee Mailing Address: Phone No.
<br />Contxactor Business Name & Number .................... Mailing Address: ph,o~ ,No.
<br />DEQ Licensed Contractor & No. Mailitlg Address: Phone No.
<br />
<br /> Site Evaluation, first 1000 gal, DSF ~ 200....~_
<br />Site Evaluation, ca, addL 500 gul. DSF 60,0( lO,O0/n
<br />Coo*~metion & Repair Permits
<br />Standard System less than 10OO gal, DSF 200.0( 10.00
<br />,S~tamiard System mote than 1000 gal. DSF:
<br />$200.00 + $15/each addl, 500 gal, DSF 10.00
<br />Capping Fill 330.0( 10.00
<br />Disposai'T-'~en'-'ehes ~n S~prollie 200.0( 10.00
<br />Holding Tank ---- 200,OO, 10,00
<br />pre~sure Distribution 280.0( i0,00
<br />Redundant System 200,OO[ 10,00
<br />Sand Filter 355,00; 10.00
<br />seepage Trench gOO.00 IO,OO
<br />Tale Dewatering System 280.0( 10.00
<br />Plan Review
<br />600 saL ~)SF, i0Ot n*l. DSF SO, O( .00
<br />(except SAND FILl'ERS)
<br />For each additional 500 gal, DSF 20,0(
<br /> Alterations 2OO,0( lO.00
<br />k~,~air,Mlnor 60.0( 10.00
<br />Construction Perbut Renewal (Field Visits) 120.0( 10,iX)
<br />Consm,¢tion i emfit Renewal (No Field Visits) 70.0( 10,OO
<br />Exi,qlJn~: System Evaiua~on Reporl 120,0( 10,00
<br />Authorization Ncalce (Field Visit) 120.0( I 0.00
<br />,.A~?dl,~o_rizad.~oa N.~oiice~(Np.~iel,d visit) 70,0( 10.00
<br />Annual Evaluation of Alternative System 120.IX I0.OO
<br />Anmxai Evaluation of Large System 75,0( 10.00
<br />Pumper Tr0¢k !n¢~!ti?~, ,F!rst track 50,0(
<br />Pumper Truck Inpeeefion, ea. addl. track 35,0( .00
<br />
<br />(Mark ff AFl ,pplitatlon)
<br /> ) Test Ilolc~ are Dug
<br /> ) I will tall when Test }Iol~ Dug
<br />
<br />) I am perflxming work on a property I own or occupy
<br />) I am a registered builder of ( ) the authori?~.d repre-sentetive
<br /> of a registered bailder,
<br />) 'llle work will be pefformexl by a DEQ Licensed hzstaller
<br />) Other
<br />) I agree to install according to the submitted plans and
<br /> SlX'eifJcalions, the laws of the Slate of Oregon and the
<br /> ordinance.x of Marion Cotmty,
<br />
<br />MC 15-74 REV 1P92
<br />
<br />Resid,nti'---;~i singl* Family .....
<br />Site Evaluation, first lot
<br />Site Evaluation, ea. addL lot 16S.OO 20.(X)
<br />
<br />Stendard System 200.00 10160 ........
<br />Capping Fill 3J01(~ '"f~-lJO
<br />l~Cssure Distribution 280.00 1
<br />Sand Filter ...........
<br />~¢~ge TTeneh 200.OO
<br />Repair, Major.{drainfield) __ '¥5,'0~ -i'07~ ............
<br />Reinsl~ction Fee 25,00 ,00
<br />
<br />Aulhod~ation Ncalce (No field visit) 70,OO 10.OO
<br />Ex/sting System EvaluatiOn ....... 1'2"i~(~ ~ ......... ........
<br />Ann~al ~v{lu~t)onfl'*m~. or Hardship MH 75.00 .00
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<br />&/4-
<br /> DATE:
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