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FOR OFFICE USE ONLY
<br />Received
<br />Zonir, g Validation
<br />Date:
<br />
<br />MARION COUNTY BLII~DiNG INSPECTION
<br />
<br />220 Hish Street NE
<br />Salem. OR 97 J01
<br />
<br />8:00 a,m.-4:30 pm Phone $88-5147
<br />Code-A-Phone 588-7904
<br />EAX$88-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />cation of Installation
<br />
<br />Job Address ,,~ ~ ~~,-- T~ A;~t, NO, Cross Street .........
<br />
<br /> ~~~. n , , Site No. , .... U~e o~tmvta~ ,,.
<br />Subdi'~isi~a ~t B~oek, Nq. ~ptoyees ....
<br />Mob e Homq,?~k,_~ ,., ~p~ ~ ..... ~o, [ ~
<br />Section Township ~,~$~ Zon~~ ~ Map ~vat~ ~{~1
<br />~t"~dth .... ~tl)cpth Ac~s ~,,,~ I~g,~t Comer Co~t*wen ~ ~s ~ ~
<br />
<br />~ C.~B~* ' Mailing Address: Phone N~.
<br />DEQ Licensed Cont~ctor & No. ,~,2 m~,~ [~~ Mailing Address: Phon~ No.
<br />
<br /> · - il ~ Flow) ..... $
<br />
<br />S te Evatoatlon~ first 1000 8al. DS,.F 245,00 20.00
<br />Site Evaluatioa~ e~{,;.~ddL 500 sah DSF 75.0,0 20.O0/m
<br />Constmetlon,, & Repair Permits ,, , .,~
<br />Standard System less than 1000 ~al. DSF 245.00 , ~,0~.00
<br />Standard Systera raote than 1000 al DSF:
<br />$245,00 + $15 e~ch,,~.ddl, $00 gal. DSF 10.00
<br />C~[ ...... 415,00 10,00
<br />D~renchcs in Saprrdite 245.00 10.00
<br />Gray W,a~pr Waste Disposal Sump IZ0,~90 10.00
<br />Holdh~g Tank ,, ¢'~5...0. 0 I0,00
<br />Pressure D!,~buiion 350,00 , ,,10.:0.0
<br />Redund,n~ System __ 245,00 10.00 ........
<br />$;~n cl Filter ..... 4a~,00 ~0.00
<br />Seepage Tr~ n=ch 245,00 ,,19.00
<br />Steep Slope ......... 245.00 10,00
<br />Plan Review ..............
<br />>.~.!?0~t~ D~F,< t00i gal. DSF IO0.OO .....00
<br />(For each add,i,[ional $00 gal. DSF 25.00 .00
<br />Altcratlnns 245.00 10,00
<br />R~pair~ M.i,p o t 75,00 10,00
<br />Construction Permit Renewal [Field Visits)~ 1S0.00 10-00
<br />Cq~t~mctlon Permit Renewal (No Field Visits) 85,00 10.00 ........
<br />Existing System Evaluation l~poz~ 150.00 ..... ~,00
<br />Authodr, ation Notice (Field Visit) 150.00 10,00
<br />Au~hndrmk, h Notice (No Field Visit) ~,60 ....... 10,00
<br />Annual Evaluation of Alternative System 150.00 10.00
<br />Annual Evaluation of Large System 90,00 10,00
<br />Pt~rnper Ttuek lnspoctlon, First track ............... 50,00 .00
<br />Pumper Track Inspection, es. addl- track , ~,,~ .,0.0 .00
<br />
<br />(Mark if Applicable to this Application) ) 'resl Holes a~ Du8
<br /> ) I wlll eMI when Test Holes Dug
<br />
<br />) I am performing work on a properly I own or occupy
<br />) I am a registerer builder or( ) the authorizer ~epresentative
<br />) I~¢ work will be performed by a DEQ Licensed Insteller
<br />) Other
<br />
<br />~e~identlal sin~ie Family $ ...........
<br />Sit* Evaluarion~ first lot ..... 245.00 20.00
<br />Site Evaluatiofs, es- addl. lot ........ 205.00 20-00
<br />Col~stmction permit
<br />Stand~?t S}/stem 24~7i{~0' ....
<br />Capping Fill ......... 41 $.00 10.0{~,,.
<br />Dish o sal Trench hl~.~j~]ii¢ 245.00
<br />Gray Water Disposal Surap 120.00 10,00
<br />Holdin8 Tank ........... 245.00 10,00
<br />Pressure Distribution 350.00 10,00
<br />R~dundant 245,00 10.00
<br />Sand Fillet 445.00 1.0,90., ,,
<br />Seepase Trench ............ 245.00 10.00
<br />S~ep Slope 245.00 ..... 10.00
<br />Tile Dewatefing .................. 350.00 10.00
<br />,~lteration 245.00 10.00
<br />Repair, M~drM ~tield) 115.00 10,00 .......
<br />Repot0 Minor(tank) 75,00 10.00
<br />Construction Permit Renewal (Field Visit) 150,00 I 0.00 .............
<br /> Construction Permit Renewal (No Field Vlsi0 85.00 10.00
<br /> Relnspcction Fee 25,00 ,00
<br /> Authofization Notice (Field Visit) 150.00 10-00
<br /> Authorization Notice (No Field Visit) 85.00
<br /> Existing System Evaluation 150.1)0. 10.00
<br /> Annual l~valuatio ~/AIt ern alive System 150.00 .00
<br /> Annual Evaluatiom'Temp. or Hardship MH 90.00 .00
<br /> Rural Area Vafianne Site Evaluation 245,00 20.00
<br />
<br /> Receipt No.
<br />I agree to install a¢cordilsS to the $ubrajtted plans and spccifications, the laws
<br />oPthe State of Oregon and the ordinances of Mafion County.
<br />
<br />NAM~APPLICANT (please print):
<br />SI N~RE OF APPLICANT: DATE:
<br />
<br />MC 15-Si REV 2/93
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