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FOR OFFJCE USE ONLY
<br />R¢ceivedCBy:
<br />Zoning Validation
<br />Date;
<br />
<br />MARION COUNTY BU-~DII~IG INSPECTION
<br /> 220 H~gh ~reet NE
<br />
<br />8:00 a.m.-4:30 pm?hone 588-5147
<br />Code-A-Phone 588-7904
<br /> FAX SS8-7948
<br />
<br />MARION COUNIY
<br />ILDiNG INSPECTION
<br />
<br /> SiteNo,¢ ~ v U}eofStmem~ ?~ ~
<br />Subdivision ....... l~t --' BI~ck ..... No. Em~loyee~
<br />Mobile Ilome Pa~ .... g~ac~ ~ ~o. 1~o. ,,,,
<br />
<br />.~C. dlntr ac t or Informatiml
<br />
<br />property Ownor Mailing Address: Phone No,
<br />Auth, AgenP'l.,e~s~,~ Mailing Add~$~: Phon~ No.
<br />Con/meter Business Nam~ & Number Mailing Add~ess; .... Phone ~o.
<br />DEQ Lic~nmd Contac/or & No. ~iling Add,ss: Phoa~ No.
<br />
<br />Commercial flY--wi
<br />Site Evaluation, es- add,L 500 gal. DSF 75.00 20.00!m
<br />Star, daM S stem lean than 1000 ~aI,'DSF 245.6(~' 10,00
<br />Slandard System more than t000 l~al. DSF:
<br />$245,00 + $15 each add], 500 8~,!? DSF 10.6~
<br />Capping Fill 41~06 I0.00
<br />p~sp!~l T~cncheS in Sapm~i~ .... 245.09 1o.00
<br />IIolding %ak .... ~45.00 10.00
<br />Pregsgm Distdbutlon ........ 350.00 ~,0.00
<br />Strop Slope 245,00 10.q9
<br />..... {For *ach additional..50~ gal DSF ~.00 .00
<br />Authorization Notie~,~ld Visit) 150.00 10-00
<br />
<br />(Mark if Applkable to this Application) ) Teat Holes are Dug
<br /> ) 1 will call when Teat lloles Dug
<br />
<br />) 1 am perfon~inS work on a pmpcr~¥ I own or occupy
<br />) I am a regislemd builder or ( ) the authorized repro~ntatiw
<br />) The work will be performed by a DEQ Licensed Installer
<br />) Other
<br />
<br />Res,dential Sblgle Family
<br />Site Eva,bmtio% ca. add[. lot 205,,,00 20,00
<br />Construction perm![ ....
<br />.,,_grandam System 245.00 10.00
<br /> Capplng Fill , 415.00 10.0~,
<br />Disoosa~ Trench in Saorolite ~4~,00 10.00
<br />Gray Wa~.r Disposal Sump ..... 120.00 ,~0.00
<br />Holding Tank 245,01)
<br />Redundant 245.00 I0.Q9
<br />S.~ 'and Filter 445.00 10.~0
<br />._.~epage 'i'~:nch 245.00 i 0.Q,0
<br />Sleep Slope 245.90. 10,00
<br />Tilc~ D~watefi.~ 350.:q9 10.00
<br />
<br />,,.Alteration ,, 245,00 ,,
<br /> Repair, Maigr (drainfield) 115,.00 10.00
<br /> l~'pair, Minor Oank) 75.00 10,00
<br /> Con,traction. Permit,, Renewal (Field Visit,, ) 15'0'i00 10-00
<br /> ~onstru¢ on Permi,~,Renc~wa (-N'o F ¢,ld Vis t) 85.00 10,00
<br />
<br /> Authorization), 15911)0 10,00
<br /> A,,..u. tho 6PElion Notice ,~NO Field Visit) 85.00 10.00
<br />
<br /> Aanu,,l Evaluation/Tcmp. or Hardship MH ' 90.00 .00
<br />
<br /> Receipt No.
<br />I agwc to install according to thc subtnitted plans and specifications, the laws
<br />ofth~ State of Oregon and thc eMinEnces of Marion County,
<br />
<br />NAME OF APPLICANT (please
<br />
<br />$IGNATIJrI3E OF APpLIcANT:
<br />
<br />MC 15-S[ REV 2/93
<br />
<br />
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