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~ '~01~oFFI'~ Cl~ ~JS~ O~IL¥ MARION CO~ B~D~G ~SPEC~N <br /> <br />/" ' JVL 0 1994 <br /> <br /> - ' ,RION COUNTY <br /> 1. Location of Installation INSPECTION <br /> <br />pcopedy Ownc;~ ) . , M~iling Add~: Phone N~. <br />Au~. AgenttLeasee ' Mailing Address: Phone ~o[~ <br />Contractor Buslncss I~la~e .e. Humber .... Mailing Add,as: Phone No. <br />DEQ~Lic~ns~d ~ontractor & No. Mailing Address: Phone No. <br /> <br />3. Fees <br /> <br /> (~0m inertial {DSF = DailwRewaee Fiow'l <br /> Slt~ Evaluationt fit~,~ 1000 ~t. DSF 245.~ <br /> S~ndaM S~em lea~,'~han ]000 gal D~ 245.00, 10.00 <br /> S~nfia~ Sys~m mo~ ~ha~ 1000 8al. DSF: <br /> ~24S.00 + ~15 ¢aeh ~dl. 500 8al. DSF 10.00 <br /> Capping Fill 415.00 10.00 <br /> Diapokal T~nche~ in S~l/tc 245.00 10.00 <br />., HoldinBTank ~ 245.00 10.00 <br /> <br />_.~cd0ndan/System , 245.00 10.00 <br /> Sa~d Filter ~$,09 I 0-00 <br /> ~cpa~e ~nch 245.00 10.00 <br /> S~p Slope 245.00 10.00 <br /> ~le D~watcfinR S~m ~0.00 10.00 <br /> >$00 ~al. DSF~<I001 ~al. DSF, I00.00 .00 <br /> <br /> (For e~h additional S00 rial. DSF 25.00 ,00 <br /> Attentions 24~.00 10.00 <br /> Repair, Minor ,; 75.0~ 10-00 <br /> , Cona/nmtion P~il ~n~al (Field Vialta) 150.00 10.00 <br /> Conslmctlon,pe~i/Renewal ~o Field Vide) 85.00 I0.~ <br /> Authod~tion Nofiea (Field Via/t) 150.00 10.00 <br /> Authofi~iSn Noti~ ~o Fifld Vi~t) gS.~ 10.~ <br /> Annual Evaluation of AIte~Mive System , 150.00 10.00 <br /> A~nual Evaluation of ~e $ys~m , 90.00 IQ.00 <br /> ~her <br /> <br />(Mark if'Appli¢$bl¢ to this Application~O ) 1 will cell when Tes Holes Dug <br /> <br />Residential Single Familv $ <br />Sit~ Evalu~io~t ~r~ lot 245.00 ~0 <br />Constm~on ~it --- <br />S~ndaM S~Mcm - 245.00 10.00 ~ ,~ <br />~pping ~iI1 415,00 10,00 ' <br />~j~o~l ~nch in gap~[i~ 245.00 <br />O~y WMcr Di~o~ Sump ,. 120.00 I0.00 <br /> ~oldin~ Tank · 24~.00 <br />P~c~ Di~fibutlon ~ 3S0.00 ~.00 <br />~undaai. 245,00 10,00 <br />~page Trench ' 245.00 10,00, <br />Steep $ op~ 245,00 10.00 <br />~tc ~w~fing ~$0.00 10,00 <br />Altc~on 245.00 I0,00 <br />~afi~c~on Pc~t Renewal (Field Visit) 150.00 1o,o0 <br /> <br />,Abtho~tion Notice (Field Visit) 150.00 10,00 <br /> <br />/~sfing S~em ~wluatlon 150.00 I0.,00 <br />~anunl Evalu~io~Al~mativc System ' 1~0,00 .00 <br />' ,Annu~ Ev~u~io~e~. or Ha~ship ~ 90,00 .00 <br />, Ru~l Ama V~anoe Si~ Evalua~on 245.00 20.00 .... <br /> <br /> Receipt No. <br /> agree to laslall according to he sub,trod pinna and specifications, tb~ lawn <br />of the S~¢ of O~gon and the OMinanccR of ~fion County. <br /> <br />~ OF APPLIC~ (please prlnt~: <br />SlGNAT~ OF APPLIC~: DATE: <br /> <br />MC 15-SI REV 2/93 <br /> <br /> <br />