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I~OR OFFICE USE ONLY
<br />Received By:
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />220 High att*et NB
<br /> Salem, OR 97301
<br />
<br />5:00 a.m. - 4:30 pm Phone
<br /> Code-A-Phone $88-7904
<br /> F,~X 5sg-794S
<br />
<br /> SITE EVAJ.~UATION ANDIOR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation '-. .a. qR2.'.~
<br />
<br />2, Cql~tract0r Information
<br />
<br />Corn i. 1 - · e Flow) $
<br />Site Evalu~,tion~ first 1000 gal, I)SF 24'~.00 20,0o
<br />$J~ Bvaluatlon~ ea. axl41, 500 ~al, DSF 75.00 ~0,0O/m ,.
<br />Constmctio0, & Repair Perm{iS ,, --
<br />Standard Syst~tn less than,1000 gal DaF 245.00 10.00"
<br />:;tan dar~, System more than,,[000 gal. DSF:
<br />5245.00 + $15 eagh addL $00 f/al. DSF IQ.00
<br />Capplal~ Fill 415,00 10.00,,
<br />Disposal Trenches ia Sapmllto 245.00
<br />Gray Water Waste D sposal Sump, 12'0,00 10.00
<br />Holding Tank 245.00 10.00
<br />., Pressure Distribution $50,00 10:00
<br />Redbndant Sgs!~m 245.00 I0.00
<br />$~nd Filt¢r 445.00, 10,O0
<br />Seepa~qe T~nch,, 245,00 10.00
<br />Stee~ Sloge '245,00 10.00
<br />Tile]Dews cling System, 350.00 I0.00
<br />>'600 ~a DSF.'<IOOI gal DSF ).Op.00 .00
<br />(For each additional 500 gal. DSF 25.00 .00
<br />C0n~ltmctio a Permit Renewal (Field Viait.~) 150.00 ~0,00
<br />Autb}o fizafion blotice [l~ield Visit) 150.00 10.00
<br />Autb,ofizatipn Notieo (No Field Visit/ , ,85.00 10.00 ....
<br />Ann0al Evalua,!ion of Alternative System 1:~0,00 10,00
<br />Annual Evaluatlon,of Largo System 90,00 I0.00
<br />yum~pey,Tmek Inapeeti.on, es, addh tm,e,k ,,SS.00 , .00
<br />
<br />(Mark if Applicable to this Application)
<br />( ) Teat Holes a~ Dug
<br />( ) I will call when T~at Ho1¢$ Dug
<br />
<br />) I am performlng work on a propeay I own or ocouFy
<br />) I am a mglstered builder o; ( ) the authorized representative
<br />) Thc work will be performed by a DEQ Li¢on~d Installer
<br />) O/her
<br />
<br />.... Residential Single Familv" $
<br />Site Evaluation~ first ,lot 245.00 ~0,00
<br />Constms~!ou permit
<br />Alteratloa 24-2100 10,00 ,
<br />Repair~ Major (d'rainfield) 115.00 I0.00
<br />Construction Permit Renewal ~Pield ¥!sit) 15o.0e 10,00
<br />,, Authorization Notice (Field Visit) 150.00 10,00
<br />
<br />[Total
<br />
<br />NAMSOF APPLICANT (please print):
<br />SIGNATURE OF ~O>?LICAI'CI': DATE:
<br />
<br />MC 15-SI REV 2/93
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