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fiOll OFFICE,' US'~ ONLY]
<br />eceiveyA' By: ~
<br />oning Vali~ltion:
<br />
<br />MARiON COUNTY BUILDING INSPECTION
<br />220 High Street NE
<br /> Salem, OR 97301
<br />
<br /> g;00 a~n - 4:30 p~n Phone 588-5147
<br /> Code-A-Phone 588-7904
<br /> FAX 588-7948
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<br />Location of Installation
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<br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />
<br />lob Ad&ass
<br />Subdivision
<br />
<br />Mohil¢ Home Park
<br />
<br />Ted Linqo
<br />
<br />Sino~&,~,n
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<br /> tMail~figAddre-qs P.O. BOX 1155
<br />Aum.qv~ lle [TaxAeet-N0-J 714..ff.Z_e~[=_0-- ~l
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<br /> Setaio. 3 1 [ 'Ibwnsldp
<br /> Lc~ Width 2 ~ 5 ~I Lot Depth
<br /> 2. Contractor Information
<br />~¢¢~d -Pr°penY Owner
<br /> Auth. Agent/l ,ea-qee
<br />
<br />Rang9 1 W Zoa¢ AR
<br />Aere.q 1 . 0~ In-ea. Lot
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<br /> Mailing Address:
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<br />I Mailing Address;
<br /> Mailing Address:
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<br />Map8 1 W- 3 ], ~23.:A
<br />Corner
<br />
<br />Phone No, 7d9-3765
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<br />Use of Slmetm-¢:
<br />
<br />Phone, No,
<br />
<br />Phone No.
<br />
<br />Phone No,
<br />
<br />Phone No.
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<br />I Commercial (DSl~-Dady,2~w!~g¢ Flow) Re~iclential Single Fa.lily ............
<br />Site Evaluation, first,]~ sial DSF , , $ 2~.~ ~20.~ $ Site Evaluationt fkst lot
<br />
<br /> Construction & RepMr Permits Cons~?on ~r~t
<br /> S andard Sys em less ~an 1~ aah DSF 2~.~ 10,~ Stan~d System ~ ' 2~.~ 10.~
<br /> Standard System m~e than 1~ gal, DSF: Capping Fill 330,~' '~f0y~ ......
<br />
<br /> $2~,~ + $15/each addl, 5~ gal, DSF 10.~ Dis~al Trench in Sapro~te 2~.~ 10,~
<br /> Capping FiE 330,~ 10,~ Gray Wamr Dis~al Sump ,, "95,~ ~0.(~
<br /> ~sal 'l?*nch~s in Sapmlite 2~,~ I0-~ }Io]~ng hnk
<br />
<br /> Pressure Distribution 280,~ 10,~ Sand Filter ....... 355,~ ~ ..........
<br /> ReduudantSyatem 2~,~ 10.~ "~e~p~g¢'l~nch ..... ~ ...... 2~.~ 10.~
<br /> Sand Filter 355.0 10.~ Steep Slo~
<br />
<br /> ~Ic DewaterJng System 280,~ 10.~ Repair, Maj~ (~d~ield) ~- 95,~ ~0.~
<br /> Plan Review Repair, Minor (rank) ~.~'
<br /> ~%0 ~al, DSE 1~1 g~. DSF 8Q:~ .~ ~ Constn~9,fion Perndt RenewM ~ield VJsJQ,, 120,< "i~):~? -
<br /> (exc~ SAND FIUI'F~S) Construction Pcmfit Renewal ~ Field V ~ ) ~. _~p.~: 10~
<br /> Cons~c~on Pern t Renewal,,{No F~e d Vmm) ?0.~ 10.~ Ann~ai Evaiuation/~ii~iv~ ~y~t~m 120.~ ,~l
<br /> Aunual Evaluation of All~rnafive System I20.~ 10.~ ~ ~ al
<br /> Annual Evaluation of,,~e System 75,~ i0,~ ~-- ~ ~
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<br />(Mark if Applicable to this Application)
<br />
<br /> Jun performing work on a property I own or occupy
<br /> aln a registered bailder or ( ) the authorized teptesentafiye
<br />
<br /> work will be performed by a DEQ Licensed Imqtaller
<br />Other
<br />
<br />rE:
<br />
<br />AC 15-74 REV 1/92
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