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MAR[ON COUNTY BUILDING INSPECTION
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<br /> F~cc~ OL'F, ICE ,~DNLY 220 High Street NE
<br /> ~,, ive~ By: ~2__ ,, ~ S~m, OR 97301
<br />] zomng Vali~tit~: ~ 8:~ am- 4;30pm Phone 588-5147
<br />~Dam: _ ~-~ "~ ~ C~A.~onc 588-79~F~ 588-7948
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<br /> SITE EVALUATION 3d~ID/OR SElrflC PERM1T APPLICATION
<br /> · Ix~mtion of Installation
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<br /> . . , / &
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<br />Mobile Home P~k
<br />~ ~wus~p TR~"~c Zone Map ~O ~f~ W.,.
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<br /> 2. ~n~actor Information
<br /> l'vo[~ay Owner "~ MailJn dd~sg: Phone ~o.
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<br />C[~?ereial (DSF,-D, aily Sewage Iqgw)
<br />L Sl~e Evah,adon, first 1000 g~l: OSF ..... $ 200,,00 ,20,00 $ .....
<br />Site Evaluation ea. addl. $00 gal. DSF 60.00 20,OO/m
<br />Standard Systc~m less ihan lO00 gal DSF >~00,00 I0.00
<br />" $200.00 4- $15/eaeh addl. 500 gal. DSF 10,00
<br /> Capping Fill ....... 336~0~ 10.00
<br /> 200.~ 10,00
<br /> ) sposa Trent os n Saprolite ,,
<br /> 95.0~ 10.00
<br /> Gray Water W~te Dispos,q Sump ....
<br /> Pressure Di,~lribulion '~80.0( 10,00
<br /> Redundant System 200,0( 10,00 .....
<br /> Sand Filter 35~..(X 10.00
<br /> Seepage ~!~eneh 200.{X I0,00
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<br /> Steep Slope 200.0( ....... 10,00
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<br /> Tile Dc~wat_e. dpg Systmn 280.00 10.00
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<br />600 gal, DSI5 I(Kll ,gal. DSF 8(I. O3 .00
<br />(except SAND FILTERS)
<br />For each ad'ditiona1500 gal. DSF 20,0() .06 --
<br />Alteratiglls ...... 200,00 10,00
<br />i ,_Repair, Miner 60,00 10.00
<br />I Coustructi0n ?crrni~ Renewal (Fi~],d Visit.~)
<br />~"l~en fit Ren~:wal (No Field Visits)
<br />L_A2?oriza,ion Notico_f~i&l Visit)
<br />~otlce (No Field Vi.qO
<br />I Other
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<br />'i~0.00 10,00
<br />70.00 lO.00
<br />~x0,00 ' T0.0o
<br />120.00 10.00
<br />70.00 10,00
<br />120.{30 10.00
<br />75,00 10.0()
<br />50,00 ,00
<br />35,0O .00
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<br />Residential Single Family
<br />S e [ valuadon~ Fa-st Io$ $ 200.0~ $20,00 $
<br />Site Evab~atlon, ea. add], lot 165.~ 20.(~
<br />Capping Fill 330.~ "
<br />Gray Water Di~al Sump 95.~ 107~
<br />Holing Tank 2~,~ 10,~1
<br />~essure D}~ibufion 280.(~ 10.~
<br />Sand Filter 355,~
<br />Repot, Maj~ (drMnfield) 95,~ 10,~
<br />Repair, Minor (tank)
<br />Construction Pernfit Renew~ (Field Visit)
<br />ConstruCtion P~rnfit Renew~ ~o Fi*Id Visit) 70.~ ..... 10.~ .....
<br />'~E~s0ng Syste'in Evaluation 120.~) I'0~~
<br />Annual Ewduatio~/AIlernative System 120.~
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<br />(Mark if Applicable 1o Ibis Application) ) 'lk~$1 ~toles a~e Dug
<br /> ) I will call when 'l~st Hole.q Dug
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<br />I am pcrt~tning work on a property I own or occupy
<br />{ am a registered builder ~w ( ) dl¢~ atlthorlzed repr~cnta~v¢
<br />of a registered builden
<br />The work will ~ ~fformed by a DEQ 1 icensed h~tMler
<br />doter
<br />[ agree to in,tall according to 0~c st~bmift~ plans and
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<br />DATE:
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<br />MC 15~74 REV 1/92
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