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FOR OFFICE USE ONLY MARION COUNTY BUILDING INSPECTION
<br /> Received By: 22o High Street NE
<br /> Zoning Validation ~em. OR97~01
<br /> Date: 8:00 a,m, - 4;30 pm Phone 588-5147
<br /> Code-A.Pbone 588.7904
<br /> FA~ 58g-7948
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<br /> SITE EVALUATION AND/Q~]gPTIC PERMIT APPLICATION
<br />1, Location of ] -o d,~/~'-*~q:~
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<br /> T . i · ~pt Block No. E loyees ...... ·
<br />Mobile Home Park
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<br />_2. Contractor Information
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<br />~0ntta~tor B~giness Name & Number M~iling Address: Phone No.
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<br />Cammercial (DSF -Dailv gew~e FIow]
<br />Sit~ l~vnluatJon, ll~ 10~0 gal, DSP 245.00 20,00
<br />Construction & Repai~ Pe~
<br />Staada~ System less than 1000 ~1. DSF 245.00 10.~
<br />S~nda~ System mo~ than 1000 ~L
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<br />Cappin6 Fill 415.00 10,~
<br />Dispo~l Tgn~hg~ }~ ~gp~lig 245.00 10,00
<br />Holding Tank 245,00 I0,00
<br />Redundant Sys~m 245.00
<br />Plan Revie~
<br /> >600 gah DSF~< 1001 gal, DSF 10~,00 ,00
<br />
<br />(For a~h ~ditiona1500 ~L DSF 25.00 .00
<br />Alie~rnna 245,0~ ............. 10.00
<br />R~gair~ Minor 75,00
<br />~onstmetion P~it Rmaewal (Fteld Visits) ,.I,50,00
<br />~nstmetion P~it Ranewml ~o Field Visits) 85,00 10,00
<br />~stlng Sy~m Evalu~ion Repo~ 150~. 10.00
<br />A u ~h o fi~tio~,.~]y~,.~i~ld Visit ) 150,~ 10,~
<br />Authod~tion Notice ~o Field Visit) ~,:~,
<br />Annual Evaluation ofI~e $ys~m 90.00 ....... 1,0,00
<br />~,nper ~ok l~speotion, Fi,t tm~k 5q,0,O .........
<br />~p~f Track lnspegtion~ ~a. add,lc3~k,' 35,00 .00
<br />~het
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<br />(Mark if Applicable to this Application) ) Test Holes ate Dug
<br /> ) I will gall when Test Holes Dug
<br />
<br />) I am performing work on a pwpeny I own or occupy
<br />) I am a ggistegd baildet dr ( ) [he authorized Zepresentative
<br />) ~e work will be peffo~ed by a D~ Licensed Ins~llcr
<br />) OtM~
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<br />Residential Single Family
<br />site Evaluatioar first~ot ................. 245.00 20,00
<br />Site Evaluation~ em addL lot 205,00 20.00
<br />Construction permit
<br />Standard 5ystcm ................. 2~5~00 I0,00
<br />C~pping Fill 415.00 10.00
<br />, .,O r?y ,W.,atc,~' Disposal Su,mP 120.00 10.00
<br />Seepage Ttench .... ~?:~.00 , , 10.00
<br />Alteration it 245.00 10.00
<br />Repairt Major (dr~infield) ............... 115.00 10,00
<br />Con~mctlon Permit l~_nywal (Field Visit) 150.00 10.00
<br />.... A~thofizatioa Notice (Field Visit) 150.00 10.00
<br />...Ap~h,crdz, ation Notice (No Field Visit) 85,00 10.00
<br />Annual Evaluatlon/Alt~mafiv¢ System .~0.00 .00
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<br />Receipt No.
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<br />NAME OF APPLICANT (please print):
<br />SIGNATURE OF APPLICANT: DATE:
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<br />MC 15-8i REV 2/93
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