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FOR OFFICE USE ONLY
<br />Received ~y:
<br />Zoning Validation ,
<br />Date:
<br />
<br />MARION COUNTY I~UILDING INSPECTION
<br />
<br /> 8:00 a.m. - 4:30 pm Phone $$6-$t47~
<br /> Code-A-PhOneFAX $86-794868"7904 jr?~3 ~ .~ t~"
<br />
<br /> SITE EVALUATION AND/OR
<br />1. Location of In6tallation
<br />
<br />~_P~edyOw~er ] MailingAddr~ss '""~" ::~ll~lqo. ,,
<br />1obAddr~ss /--~,~ ~~ ~ S~ T~Acct, No.
<br /> ~ Site No, Use of Structure
<br /> SubdiviSion ~t .Blo~k No.
<br />
<br /> 5eclion ' To~s~,ip ,, ~n~ Zone Map wa~au 1~:
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<br />2, Contraetor llmf,)rmati0q
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<br />Property Owner Mailing Address: Phone No.
<br />Auth, Agent~Lcaseg Mailing Address; ?hone No.
<br />C~itxaetor Busihess Name & Numbgr Mailing Address: ' Phone N~.
<br />DEQ i,icena~d Contractor & No. Mailing Address: Phone No.
<br />
<br />eom i I - : I ' )
<br />Site EvaluationI first 1000 gal. DSF 245.00 20.00
<br />Site Eyaluatlon ga. addL,,$00 gal. DSF 75.00 20.00/m
<br />Coqstmerion & Repair permits
<br />5,?,ndard System less than I000 [9!' DSF ~4~:00 I0.00
<br />Standard System,,mom than 1000 {gal. DSF:
<br />$245,00 + $1~ ea~h addL ~00 8a[~ DSF 10.00
<br />Capping Fill 416.00 ,, 10,00
<br />_.Disposal '£r~nohes in ~aprolite 245.p0 10.00
<br />Gray Water Wasta,.Disposal Sump 120.610 10.00
<br />Holding Tagk 245.00 10.00
<br />Yr0ssum Distribution , . 350.00 I 0,00
<br />Rodund~nt System 245,00 I~),00
<br />Sand Filial 445.00 I II 10'09
<br />~eepage Trench .... 245,00 10,00
<br />Steep glop* 245.00 I0.00
<br />Tile D~wate rlng, System 360.00 10.00
<br />..... Plan Review
<br />>600 gal. 'D~F~<I001 gal, DSF 1.00.00 .00
<br />
<br /> .... ,Conslructlon Permit Renewal (Fi'eld VisiiO ~0.00 10.00
<br />
<br /> Authodr~tion Notle* (Field Visit) 160.00 10,00
<br /> .... Annual Evaluarion, of La~e System 90.00 10,00
<br />
<br />(Mark if Applieafile to this Application) ) Test Holes are D~g
<br /> ) I will call whgn Test Holes Dug
<br />
<br />) [ am performing work on a pVOpe t~y ! own or o¢¢tlpy
<br />) I am a registered builder or ( ) the authorized representative
<br />) 'ille work will be ped'o nned by a DEQ Licensed Installer
<br />) Other
<br />
<br /> Residential Sin~'l~ Yam,fly 6
<br /> Sit* Bvaluation~,,fifst lot 24 ~",~)0 20,00
<br /> Site Evaluation~ ea~ addl. lot 205.00 20,00
<br /> Constru¢~i,on pgrmit
<br /> Standard b~stem 24~,00 10,®
<br /> Capping Pill ,, ..... 41~.00 10,00
<br /> Disrmsal Trench .in Saorolite 245.00 .... 10.00
<br /> Gray Water Disposal Sump 120,00 10,00
<br /> Holding Tank ; 245.00 10.00
<br />, ,,pressure Distribution 350.00 10.00
<br />Redundant 2~fl.,00 10.00 ,~
<br />Sand Filter 445.00 10.00
<br />Tile De'~atefing 3~0.00 10.00 ....
<br />Alteration 245,00 10.00
<br />Repairl Major (drainfield), 115,00 10.00 ,
<br />Repair, Minor (tank~, 75.00 10.00
<br />Construct!on Permit Renewal (Field Visit) 150,:00 10,00
<br />Constmq~ion Permit Ren~wal,(No Field Visit) 85.,q0 10.00
<br />Authorizatioti Noticc (PieM 'Vlsi0 '150.00 10,.00
<br />.Authoriza on Notice (No Field V sit) ,, 85.00 ,10.00
<br />Existing System E'q$1uation 160.00 10,~,.00
<br />Annua!,l~valuation/Altemativ~ System 1,~9.00 .00
<br />Annual EvaluationFr~mp. or Hardship MH 90.00 ~00
<br />Ruin} Ar~a V~'tiance Site ]~valuafion 245.00 20.00
<br />
<br /> Total 6
<br />
<br /> Receipt No,
<br />I agt*o to install a¢¢oMing to the submitted plans and ~p¢¢ifiCations, the laws
<br />of the State of Or, gpu and the o~inances or,flea County.
<br />
<br />N~F APPLIC~ (please print):
<br />
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />Mi.: 15-SI REV 2/93
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