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220 High Street NE {J ~,~ ,~ [~')
<br />Salem, OR 97301 ,~ ~ ~
<br />
<br />~ FOR O'PF]~E USE ,ONLY [
<br />kceeiv By
<br />[Zoning Validation!~ ~ 1 I Phone588-SI47
<br /> c~.~.~o.~ s88-~ ~A~iON COUNT~
<br /> s~ ~r~iox ~o~ s~c ~ ~c~lo~UIL~INa INSPECTION
<br /> l, l,~ation of lns~llatlon , ~/~ ~
<br />
<br />2. Contractor Information
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<br />Property Owner Mailing Address: Phone No.
<br />
<br />Auth, AgentJLea~ee Mailil~g Address: Phone No,
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<br />CooUaetor Business Namo& Numl>~ Mailing Address; Phone No.
<br />DEQ Licen:,ed Coutractc¢ & No, Mailing Address: Phone No.
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<br />Commersial (DSF-Daily Sewage How)
<br />Site Evaluation. first IOOO gal. DSF $ 200,00 [20,OO $
<br />Site Evaluation, ea. addL 500 gal. DSF 60.0( Z0.OO/n
<br />Cons~nletion & Repair Pemfita
<br />Standard Sy~iem less lhan 1000 sal. DSF 200.0( 10,00
<br />Standard System mO~e than IOOO gal. DSF:
<br />$200.00 + $1 fi/each addl. 500 gal. DSF 10.00
<br />...... ~,?~,!~,y!l}, , 330,0( to.oo
<br />Gray Wat~c.-r Wattle [~!~po~a!, Su?p, 95.0( 10,00
<br />{~pa~.2_'l~neh ZOO.iX IO.OO
<br />Alterations 200.0~ 10.00
<br />Constmetlon Permit Renewal (No Fiel2l_ V,!5!!:), ......... 70. OO 10,OO
<br />.~Eaisfi!!g~S Fstent r' valuation Re[xm I g0, OO I0.OO
<br />Amhorlzation Noa,c:,.(~'i~l_q,.¥!,,5!!Z ................... 120.00 10.OO
<br />Annual Eva]~,~_a,~!.gE?f~J!c_'[n_~_t!v_.e_lq,y~!~,n,,}__, I20.00 10,00
<br />
<br />(Mark if Applicable to tiffs Application)
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<br /> Realdenfial Single Family
<br /> Site Evaluafion~ first lot $ 200. OO ;20.OO $
<br /> Site Bvaluation, ea. ad<IL lot I65,OO 20.00
<br /> Construction pexmit
<br /> Capping Fil! 330.00 10.00
<br /> Disposal 'French ia Saptolite ,2OO.OO 10.0~ ........
<br />
<br />~ra~ Wa~er Dispe,~al Sump 95.00 10.00
<br />IIolding Tank Z00.OO 10.OO
<br />Pr~ssor~ Distribution 280.00 'q~T{~ ........
<br />Redundant 200.00 10.00
<br />Sand Filter 35.5100 10.OO
<br />Seepage ~l~nch 2OO,OO IO.OO
<br />Steep Slope 200.00 l
<br /> 2~0, OO '-1'670~
<br />, wi!e,r~w~o.g ........
<br />Alteration " 200,00 10.OO
<br />Repair, Majtx (dtaim%ld) 95.00 10,OO
<br /> Repair, Minor (tank) ~ --~O,--~j(~' 1-~
<br />
<br /> Conatrucfion Perufit R~newal (Field Visit) 120.OO 10,00
<br /> Construction l'etmit Renewal (No Field Visit) 70.00 10.00
<br /> Roinsl~Ction Fei, 25.OO
<br /> Amhofization Nc~iee (Field Visit) 120.iX I0,00
<br /> Authofiz.~ion Noti~ (No field visit) 7{X~ 10~
<br /> Existing System Evaluation 120~iX fl)TOO
<br /> Anmml Evaluation/Ahernative System 120,00 .OO
<br /> A,a!~al Evahmtionfl'emp. or Hardship Mil ¢5.OO
<br /> Rural Area Variance Site Evaluation 200.00 20,00
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<br /> atna regislered bulkier or ( ) the authorized
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<br /> work will ~ ~'rform~ by a DEQ Li=nsed
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<br />s~il'ication~, tim laws of the Slate of ~egon and
<br />ordinanc~ of Marion Count y.
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<br />Receip NO. lt)~~)
<br />
<br />DATE:
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