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FOR OFFICE USE ONLY
<br />Received By: __
<br />i l~:tr~g V~41idafio i
<br />
<br />MA RION COUNTY BUILDING INSPECTION
<br />220 High Street NE
<br /> Salem, OR 97301
<br />
<br />ge00 am - 4:30 pm Phone 588-514'/
<br />Code-A-Phone 588-7904
<br /> FAX 588-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PEPdMrr APPLICATION
<br /> Location of Installation
<br /> Maihag Ad&eS~ax Acer, No' TL4t
<br /> ,. -- IL~ [Bilk
<br />So~iviaion ~~ ~ ~ ~ ~
<br />
<br />Section ~,~ ] Township ~ Range 21-0 ,,
<br />Lot Width [ Lot Depth Acres . ~-, ] ~
<br />
<br />2, Contractor Information
<br />
<br />DEQ Lieen.~cd fTon/rac/or & No.
<br />
<br />Mailing Address:
<br />
<br />Cro~s Street
<br />
<br />No. Employeen:
<br />
<br />Phone No. ~,~ t.,~-~ g ~',~ ~'
<br />
<br />Mailing Addrens: ~ ~e No.
<br />Mailing Address: . / [ I Ph°n~l~:.
<br />Mailing Address; j Phofle No,
<br />
<br />3. Fees
<br />
<br /> Commercial (DSF-Daily Sewage Flow) I I III Rasi~l l ' l .....
<br /> S._~teEvahiafion, firat O00gM. DSF q{ ~'/~.,..~$ 2~bOO~00- 8~ ~ ~'~iteEvaluafion, fir~tlotill ~,~ $ 1200.00 $20.00 ~ll~
<br /> Site B~.{~!,ua~Jon, ~t, addl. 500 ~a~,~], DSF *~< 60,00 20lO0/u ' l.l~il[e EyalU~riOn, e,a. add], lot J 165,00 20100
<br /> Construction & Repair Peerdits '- I ' )lb ~
<br /> Sland~d S ,~=,{'"i,ss am mOO gal. 0SF "' 200.00 16.00 '-'
<br /> ~'~ . ...... Starred Systm ~ 9- :~O'" 2OO:00 mOO
<br /> Stud fid System mor~. hen 1000 gal. DSF: Capping Fill ~ 330.00 10.00 ....
<br /> $ 2 O0 '~O~=lll~'' $I5/each addl. 500 gal. DsF 10.00 Disposal Trench i~ Sapcolite~ ~ -I I 2~
<br /> Capping Fill ' 336,'~ 10.00 Gray Water Disposal Sump ' ' 95.00 10.00
<br /> :-J'Jlsposa!,,,'.rr~nche$iaSaprgi'ite 200dX 10.00 Holding rank .......... 200.130 10;00 .......
<br /> Gray Water Wa,qfc Dispose Sump .... 95.0( 10.00 Pre*sure Dis~i6htioa 280.00 I0.00
<br /> Holding Tank 200.0( 10.00 Redundant 200,00 10,00
<br /> Pressure Distribution 280dX ! ,10~00 Sand Filter 355.00 '"10.~)
<br /> Red,indent System 200.0( i0.00 Seepage Trepeh ' 200.0~ 1'0,00
<br /> Sand Filter 355.0 10.00 Steep Slope_ ..... 200,0~ 10,00
<br /> ..... ~epage Trench . 200.0~ 10.00 Tile l)ewatering gg0,0~ 10.00
<br /> Steep Slop~ 200.0(] 10,O Alteration ........ 200,00 10~O0'
<br />
<br /> Plan Review Repair, Minor (tanhi 60.00 10.00
<br /> 600 gal, DSF, 1001 .g?. DSF ~ ' 80.00 ~",,,:00 Constru..yion Perndt Renewal (Fie!¢ XJisit) '"i'~O.O 10.00
<br /> (~xct~pt SAND I:'f.L'iERS) ...... Consmactlon Pemfit Renewal (No Field Visit,) ...... " "70,~ I0.00
<br /> For each 0xlditional,,~O0 gal. DSF 20.00 .00 Reinspec~Jon Fee 25.00 .00
<br />"Alterafiol:z ...... 200.00 10,00 Au&odr. afionNoOee(FieldVisit) ,. ' ....... 120.00 10.~
<br /> Repair, Minor ,, , 60.00 10.00 Au&osizafion Notice (No field Plait) 70.00 10.00
<br /> Conmmclio, Pt, rmi['l~ne(val(PiehlVisit.O" 120.~0 10.00 E~ist~ ~fl Symem Evalualkm 120~0(~ ~' '10.00
<br />Coosh-uction Pennil Renewal (No Field Visit,0 ?O. IX) 10.00 Annual Evaluatiou/A t~atlv,~y~m ~.~ ' 120,00
<br />Erisdng,";ystem E~y~,aUon Rep~rrt i20.00 10,00 Annual Evaluation/'] ~l~.~-or~zrc~{~~ ?~ 75.00 ,00
<br />Au~porjzation Notice (Field V!,~it ) ~ "~),0( 10,00 Rural Area Variance ~V~fi~~ ] ~1~
<br /> Amhodzafion Notice (No Field Visit) 70.0( I0,00~ I, ---
<br />
<br /> Aar'ualV-valuationofLa~eSymem 75.mi lO.O0 ~ Jg'0~ ~/
<br />.....P~rapet Truck Inapcction p!~t Lruck 50,0( .00 Race pt No
<br />
<br />(Mark if Applicable to this Application)
<br />
<br />~,) %st Illole,~ are Dug
<br /> ) I will call when Test llole~ Dug
<br />
<br /> ain performing wo~k on a properly [ own of occupy
<br />am a nlgistered builder or ( ) the authorized repre,~entative
<br />ora reglslered builder.
<br />l]~e work will be peribmw~ by a DEQ Licensed Installer
<br />ethel'
<br />agree to install according to &e subm}tled plans and
<br />spe~illications, tim lawn of'the S/ate of Oregon and the
<br />ordlnanc~q of Marion County.
<br />
<br />NAME Q~APPLICAN1' (~lease print):
<br />
<br />SIGNATURE OF APPLICANT:
<br />
<br />MC 15-74 REV 1/92
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