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Zoning ~'aJidatign, ~ I/,', ,it,;/'t' Salem.
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<br />1. Location of Installation S~E EVALUATION ~/OR SEPTIC
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<br />7,, Coatractor Information
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<br />P~peayOw~er O~e~ ,, ~OYxV ~C. ~ ¢ I ~ ~ilia~dd~ss:
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<br />Con~r~r.%_~ ,Business Name~¢~:~/~v ~ Number ¢,~ ~.sT,' ' ~ ~q ~ Mailing Add~ss: ~q ¢ & ~i ~ ~ ~ ~ae Phone No.
<br /> Licensed Contractor & ~o. / ~ ~ ~ ~ ff ~iling Add~ss: Phone
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<br />LComm~r¢ial (DSF - Daily Sewaee lq°w$ I
<br />SiIe ~valuatlonr ~mt lO00 ~, DSP 245,00 20,00[ ,,,
<br />Si~e ~valu~t[on~ ea. ~dJ' 500 ~al. DSF 7~.00 2~'.00/m
<br />Standard Sys~m less ~han 1000 8aL DSF 24S,00 10.00
<br />S~a~da~ Sys~m mdg ,~han ~000 ~1.
<br />$2~5,00 ~ $15 each ~dL 500 rial DSF 10,~0
<br />Capping Fill 415.00 10,90
<br />Disposal ~ne~¢s in $ap~,li~ 345.00 I0.00
<br />O~ W~tet Was~ Dispo~l $u,mp 120.00
<br />Holding Tank 245-00 10,00
<br />?~s~um DistgbufiOa 350,00 10,00
<br />,~cd~ndant $y~tem 245,00 1~,00
<br />Seepage T~nch 245,00 10,00
<br />St~p Slope, 245.00 10.00 ....
<br />Plait RevieT
<br />>600 gal DSF,<~001 g~l. DaF 1~0.00 ' .00
<br />(¢xceo[ g~O Pit
<br />Ahe~fions 245,00 10.00
<br />ReE~ir~ Minor 75.09 10.00
<br />Constmctipn Pe~it Renewal (Fiel~ Visits) 150,00 ,10.00
<br />Const~ctlon Pe~it ~new~l (No Field Visits) . 85,00 10,00
<br />~[stin~ Syste ~ Evalu~tlon ~poA ~50,00 10,00
<br />A~thVfi~tio~ Nq~ie& ~o Field Vialt~ 85.00 10.00
<br />Annual Evaluafio~ of AItem~ive System 150.00 10.00
<br />Annua~ Evaluation o~e System 90.00 10.00
<br />PumpR~ Track Inspeqtlon, Fi~ tmek 50.00 .00
<br />~mper,,Tmek Insp~efion~ ea. ~dl, tmgk 35.00 ,00
<br />Other
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<br />(Mark if Appllcable to this Application) ) Test Holes a~ Dug
<br /> ) I will call when Test ffoles Dug
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<br /> I am performing work on a property I own or occupy
<br />) I am a registe~d huil&r Ot ( ) the authorized r~pv~seatatlve
<br />Thc work will be performed by a DEQ Lieen~d Installer
<br />Other
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<br />Residential Single F#m,ily
<br />site Bvaluation, fi~t lot 245.00 '" 20.00
<br />Site Evaluationt ea. addl. Io~ 205.00 20.00
<br />~ns~mc.tion pemait
<br />S~naa~ Sy~em 245.00 I0.00
<br />Ca~ing Fill 415.00 10.00
<br />~i~o~l Trench in ~p~lim 245.00 ~.00
<br />O~y ~at*t Disp~l Sump 120.00
<br />~*laiag Tank 24~.00 10,00
<br />P~ssu~ Distn%ution 350.00 I0.00
<br />Redundant 245.00 ,10,00
<br />S~d Fillet ~5,00 1~.00
<br />~epa~e T~neh 2~5.00 IO.QQ
<br />Steep Slgpe 245.00 ,,10,00
<br />~e Dewa~8 350.00, 10.00
<br />Al~mion 245.00 19.00
<br />RepMn ~no~,(~nk) 75.00 10,00
<br />Cgnametion Pe~it R~n*wal (Field VisiO' 150.00 10.00
<br />Raipap~ctloa Fee,, 25.00 .00
<br />Autho~tlon Notice (Field Vlsi0 150;O0 '"10,00
<br />Authofi~ion Notice,,~Na Fie~d Visit) g~.0O 10,00,
<br /> ~isfing ~y~em Evaluatio~ . 150,00 10.00
<br /> Annual Ewluatlo~Al~mative S~tcm ltl0,00 .00
<br /> Rural A~A V~a~ce Si~ EvOcation 245.00 20,~
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<br /> Receipt No,
<br />I agree to inst~ll according to the submitted plans and specifications, the laws
<br />cf thc State of Oregon and the ordinances of Marion County,
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<br />NAME OF APPEI'CANT (ple~ase print):
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<br />~IG~ATURE OF kPPI4~ANT: f DATE:
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<br />MC 15-S[ REV 2/93
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