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F0R~ OFFiC,.E. I~ OI~IL¥
<br />Received By:
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation !/N~y~, t>~
<br />
<br />~0~'
<br />.... ~bdivisioa K~SkL- ~;[ Pl4~b. ~ ~t /~ Block ~ ~o.~010VeeS
<br />Mobile Ham~ Pnrk
<br />...... I
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<br />_2, Ggntraet0r Information
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<br />Property Owner I Mailing Address: phone No.
<br />
<br />Aulh Ageni/Leasee ' MailingAdfll~ss: ?'hone No.
<br />
<br />Cont~cotBosinessNamo&Nu 'er .......................................... ailin Add s: PhoneNo. ',-. ~, ~--. ~,
<br />DEQ Licen~d Cont~tot & No. ~iling Address: Phone No.
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<br />C[-"~'-oomm~rei~i IDSF - Daily Sewage Flow)
<br />Site Evaluafion~ first 1000 gal. DSF 245.00 20-00
<br />Site Evalua0on~ ea. addh 500 gal. DSP 75,00 20,00/m
<br />Constmction & Repair Permits
<br />Standard System less than 1000 iai, DSF 245,00 ' 10.00
<br />Standard System more than 1000 ial, DSF:
<br /> ~24~i00 $ S~5 e~ch addl. 500 gal. DSF 10.00
<br /> , ,C~ppin[~ Pill 415.00 10.00
<br /> ~o~I Tr*nches in Sapmlite 245,00 10,00
<br /> GmyWaterWasteDisno~JSump ! 120.90 ] 10.00
<br /> Holding Taok 245,00 !0,00
<br /> Pressure Distribution 350.00 10,00
<br /> Redundant System 245.00 10,00
<br /> $80d Yi}t,r 445,00 lO,00
<br /> Seepage Trench 245,00 : 10,00
<br /> Steep Slope 245,00 10,00
<br /> Tile l)ewat¢dn Sg~m~ 350.00 10,00
<br /> Plan Review
<br /> >600 gal. DSF,< 1001 gal. DSF 100.00 .00
<br /> (For each additional 500 gal. DSF 25.00 .00
<br /> Repaiq Minor 75.00 10.00
<br /> Coaslraetioa pelmnit R&newal (Field Visits) 150.00 10,00
<br /> Co0slmetion permit Renewal (No Field Visits) 85-00 10,00
<br /> Existing System Evp!qatloa Repoit 150.00 10.00
<br /> Aathodz~tion Notice (Field Visit) 150-00 10-00
<br /> Authorization Notice ~No,,F[eht Visit) $5.00 10-00
<br /> Annual Evaluation of Al/ernatlve System I 150,00 10,00
<br /> Annual Evaluation of]Large System 90,00 10,00
<br /> Pumper TRick Inspection, First trick 50,00 ,00
<br /> Puml~er Track Inspection, ea. addl. truck 35,00 ,00
<br /> Other
<br />
<br />(Mark if Applicabl~ to this Application) ) Teat Roles are Dug
<br /> ) I will call when Test Holes Dug
<br />
<br />) I am pen%nninS work on a property I own or occupy
<br />) I am a registered builde~ 0r ( ) the authorized rep re~en~ative
<br />) The work will be performed by a DEQ Licen~d Installer
<br />) Other
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<br /> Residential ginele Family
<br /> Site Evaluation~ fit-at lot 245,00 20,00
<br /> Site Evaluation~ em addl. lot 205.00 20.00
<br /> Constmctlon permit
<br /> Standard System 245.00 10.00
<br /> Capplng F}II 415,00 10-00
<br /> Disposal Trench in Sapmlke 245-00 10,00
<br /> Gray Water Disposal Sump 120.00 10.00
<br /> Holding Tank 245.00 I0.00
<br /> P~ssut~ Distribution 350.00 10,00
<br /> Redundant 245.00 10.00
<br /> Sand Filter 445.00 10.00
<br /> ~eepage Trench 245,00 10.00
<br /> Steep Slope 245,00 10,00
<br /> Tile DewaterinS 350.00 10.00
<br /> Alteration 245,00 10,00
<br /> RepairI Major (dminfield) 115,00 10,00
<br /> Repair, Minor (tank) ............................. 75.00 10.00
<br /> ,,C9~,sttucti°n permit Renqwal (Field Visit) 150.00 10.00
<br /> Constmcdon Permit Renewal (No Field Visit) 85.00 10.00
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<br />, ,,,~,i,n,sp,qction,,~ce, , , 25-00 ,00
<br /> Authorization Notice (Field Visit) 150,00 10,00
<br /> Authorization Notice (No Field Visit) 85.00 10.00
<br /> Existing System Evaluation 150,00 10,00
<br /> Annual Evaluation/Alternative System 150,00 ,00
<br /> Annual Ev alu,a. !! o.~( f ?.rap,, or Hardship MH 90.00 .00
<br /> Ret'al At~a Variance Site Evaluation 245.00 20-00
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<br /> To ,* 7_ 55
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<br /> Receipt No.
<br />I aRgO to install according to the submitted plans and specifications, the laws
<br />of the State of Oregon and the oMinane¢s oration County.
<br />
<br />NAME OF APPLICANT (please print):
<br />SIGNATURE OF APPLICANT:
<br />
<br />DATE:
<br />
<br />MC 15-SI REV 2/93
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