|
FO~R OFFICE USE ONLY
<br />Received By:
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />220 High Street NE
<br /> Selem, OR 97301
<br />
<br />8:00 a.m, - 4:30 pm Phone 588-5147
<br />Code-A-Fholle 588-7904
<br /> FAX 588-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br /> ~1~ ~,~' D~ ~Od~ Slte No. Us~ of Stmctu~
<br />Subdivision ~t Block ......
<br />Mobil~ l'[om~ Park ............. Soac~ ~ ~o, I
<br />
<br />_.~Contractor Information
<br />
<br />Pmpeay Owner Mailing Address: Phone No,
<br />Auth, AgcnffL~aa~e Mailing Address: ?hone No,
<br />~oMractorBusinessName&Number .................... ~l~i[i~"X~'[Iress: Phone No,
<br />DFJ~ Licensed Contractor & No. Mailing Address: Phone No.
<br />
<br /> Commercial IDSF~D- ailv~.31~g,.Elgw) $
<br /> Site EvaluationI first 1000 rial, DSF 245.00 20-00
<br /> Site Evaluation, es, addl, 590 ga-L DSF 7100 20,O0/m
<br /> Construction & Repair Permits
<br />...... .S. tandard System less than 1000 8iai, DSF 245,00 10.00
<br />Standard System mom than 1O00 gal. DSF;
<br />Cappln8 Fill 415.00 10-00
<br />Disposal Tmneh~ in ~pmlit¢ 245,00 10.00
<br />Gray Water Waste Disposal Sump 120,00 10,00
<br />Holding Tank 245,00 10,00
<br />Pressure Distdbution 350,00 10,00
<br />Redundant System 245,00 10,00
<br />SandEilter 445,00 10,00
<br />8...,.~ge Trench 245.00 10,00
<br />Steep Slope 245.00 10,00
<br />Tile Dewatefi~g System 350-00 10,00
<br />Plan Review
<br />>~00 gal, DSF,< I001 gal. DSF '['99-,09 -00
<br />(For each additional 300 rial, DSP 25,00 ,00
<br />Repair~ Minor 75.00 10,00
<br />Construction Permit Renewal (F~el..d.,V.,{;)i';}":": ' t SO.00 '0-00
<br />Conslmetion Permit Rer~ewal 0q'o Field Visits) 85.00 10,00
<br />Existing System Evaluat on Report ,.i,,~,Q,00 I0.00
<br />Authorization Notice (Field Visit) 150,00 10,00
<br />Authorization Notice (No Field Visit) ......................... 85.00 10.00
<br />Annual Evaluation of Altel'nativ¢ $yst*m 150.00 10.00
<br />Pumper Track lnspeetlon~ First truck 50,00 .00
<br />
<br />(Ma~k if Applicable to this Application)
<br /> Test Holes are Dug
<br /> I will call when Test Holes Dug
<br />
<br />) 1 am performing work on a property I own or occupy
<br />) I am a ~giste~d builder 0r ( ) the authorized r~pmsentative
<br />) The work will be performed by a DEQ Li¢ensed Installer
<br />) Other
<br />
<br />Residential Single Familv
<br />Site Evaluation~ fimt lot 243,00 20.00
<br />Site Evaluation, es, addl, lot 205,00 20.00
<br />Constme~ion
<br />Standard System 245,00 10,00
<br />Capping Fill 415.00 10-00
<br />Gray Water Disposal Sump 120,00 10,00
<br />Holdin.q Tank 245.00 10.00
<br />......P~.s~Rr~ ..l~i~[rib, t.ion' 350.00 tO.O0
<br />Redundant 245,00 10,00
<br />Send Filte~ 445,00 10.00
<br />Seepage Trench 245,00 i0.00
<br />S~ep Slope 245.00 I0.00
<br />Tile Dewatefing 350.00 10.00
<br />Alteration 245,00 10.00
<br />R~pair~ M~jor (dminfield) 115,00 10,00
<br />Repair, ~Ot (tank) 75.00 10.00
<br />Construction Permit Renewal (Field Visit) 150.00 10,00
<br />Construction Permit Renewal {No Field Visit) 85,00 10,00
<br />...Re,i,p,sl>~ction ,Fee 25.00 ,00
<br />Authorization Noti¢e (Field Visit) 150.00 10.00
<br />Aulhorizatior~ Notice {No Field Visit) 85,00 10,00
<br />Existing System Evaluation 150-00 10-00
<br />Annual Eva] uati. o., .n/,A!,t ?lati,v9 System 150,00 ,00
<br />Annual Evaluationfremp, or Hardship MH 90.00 ,00
<br />"' Rural Ar~a Variance Site Evaluation 24,5.00 20,00
<br />
<br />Total $
<br />Rece pt No
<br />I agree to install acco~it~g to the submitted plans and specifications, the laws
<br />of the State of Oresol~ and the ordinances of Marion County.
<br />
<br />/GNAI~'g~T~ RE O~F Ap~' ANT:
<br />
<br />print):
<br />
<br />DATE:
<br />
<br />MC 1S-Si REV 2/93
<br />
<br />
<br />
|