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F()I~ OFFICE USE ONLY
<br />ReCeived By;
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br /> 220 High Str~¢t NE
<br /> SMem, OR. 97301
<br />
<br />8:00 a.ul,- 4:B0 pm Phou~ 588-5147
<br /> Code-A-Phone 588-7904
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Lecati0n Of Installation
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<br />Subdivision ~d~ ~, [~t /~ Block /"~ No. Emplovecs
<br />
<br />, ,1 ,~C~ btm atioa
<br />
<br />auth, agenl/I~a~c l~ilit~g Addrgas; J { phone No.
<br />Contract~ Business Name & N~mber Mailing ~d~ss: i Phone ~0.
<br />DEQ Licen~d Contractor & No. ~iliu$ Address: Phon~ No~
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<br />(TOm~'~rcial (DSF - Dai'lv gowat,~ Flow~ $,
<br />, ,Sile Bvaluation~ fits!, 1000 ~1. DSF,, { 24~.0~ 20,00
<br />Cappln6 Fill . 41~,00 10,00
<br />_R~dundant System , 245.00 IQ,.00
<br />
<br />,~pag* Tgug~,, 24~,~ ,10.~
<br />
<br />,,>600 ga!c DS~,~1001 gal~ Dg~ 100.0~ .00
<br />(For each.b0ditioaM 500 gal. DSF 2g.00
<br />~$ting System ~valuation ~Do~,. 130.00
<br />Authori~iion Not{ce (Field V{~it) 1 ~0.00 ,10.00
<br />Authofizalion Notice ~o F{Fid vlsi0,, 8~,0,0 i0.00
<br />Annual ~valuatiqn of AIte~ati~ System 1~0,00 10,00
<br />
<br />(Mark il'Applicable to this Application)
<br />(~0 Test f/oles ag Dug
<br />( ) I 'gill call when Test/lolcs Dug
<br />
<br />) I am a wgi:itered builder Or ( ) the authorized representative
<br />) The work will be performed by a DBQ Licensed Installer
<br />) Olhcr
<br />
<br />'"Residential ginoie Familv
<br />Site Evalu~tionr..fir~t lot 245~00 20,00
<br />Construction p~it
<br />$~ndaM Syaem 245,00
<br />~apping ~ll 415.00 10.00
<br />~nosal ~nch in Saomlito 245,00 10,00
<br />O~y Water Disposal Sum,, p 120,00 10,00
<br /> ~9Ifiing Tank , 245,00 I~,O0 ,,,
<br /> Pr~ssu~ Disthbution 350,00 10.00
<br /> ~undaul 245,00 10.00
<br />.... Sand Filter 445,00 10.00
<br />
<br />Steep Slopp 245.00 I~'
<br />Tite~,a~fiug 350,00 ~ ~10.00
<br />,~Major(dminfi=ld) ~5,00- ' 10.O0'
<br />Constmctio~ Pem~ Renewal, (FieM"~) ,, 150.00 10,00
<br />Constn.ctlon Ye~i/Ren~waI (N~e Id Visit) 8,5 00 10.00
<br />R¢inzpv~tion Fee 25.Q9 .00
<br />Autho~tion,~oti~e (Field Vis,t) IS0.00 10,00
<br />Authorization Norioe (No Field Visit) ,8~.00
<br />~iatlng Sv~m Evaluatio~ [,50,00 10.00
<br />...... Annual Evaloatio~Al~mgtiw Systvm 1~0.00
<br />Annual Ev~uatio~e~p. or HaMship ~ 90.00 ,00
<br />~ml Ama V~anc~ Site Evaluation 243.00 20.00
<br />
<br /> { otal, ;q55.oo ]
<br /> R~oeipt No,
<br />I ag~ to install ac¢ordlns to the submitted plans and spcdfications, the laws
<br />of the S~te of Oregon and the o~inanccs of Marion Count.
<br />
<br />MC 15-SI REV 2/93
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