Laserfiche WebLink
FOR :~FFIt. gE USE ONLY <br /> Received By: ..... <br />17xa~ing Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:% am - 4:30 pm Phone 588-$147 <br /> Cod~-A-Phon¢ 588-7904 <br /> FAX 558-7948 <br /> <br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br /> <br />1. Location of Installation <br /> <br />Job Addra.~ <br /> <br />Mobile l-tome Park <br /> <br />Sec ion I T°wnshiR Ra.nge <br />Lot Widl], I Lei Depth Aeras <br /> <br />2. ContractOr Information <br /> <br />I)I~.Q kaci, llsed Contractcx & No. <br /> <br /> b~aillng Address: <br /> Mailing Address: <br /> <br />Mailgn~ Address: <br />1 Maiii~g Address: <br /> <br />Phone No. <br /> <br /> 3. Fees <br /> Com;nerci.l rD~F--Daily Sewage Flow) "' <br /> Site Ewluafion~ first. 1~ ~a]. DSF .., $ 2~.~ $20.~ $ <br /> <br /> Con~2cf~a & g?pair Per~ <br /> ~*flard Sy~t0m l~s~ dl~a 1~ gal. D~F 2~.~ 10.~ <br /> <br /> D~sal Trenches in Sa )tolim 2~.~' 10.~ ~ "~ <br /> <br /> Holding Tknk '" 2'~.~ I0.~' <br /> Pr~s?re Dis~ib~on 2g0.~ <br /> <br /> St~p SI~ 2~.~ 10.~ <br /> ~le Dew,S*ring Sy~lem .... 280.~ 1,9-~ <br /> ~a¢ Review <br /> 6~ gal DSP; I~'~ gal DSF "80.~ ...~ <br /> (~xcep[_S AND FII.JFERS f <br /> <br />(?o~Imcfion P~rmit Re~ew~ ~iold Vi~ B) ...... 12ff~ <br /> <br />Aufflori~Oon Nmice (~o Field Visit) , 70.~ i0.~ <br />Aafalal Ev~luatiortof Allernafive 8yst.~m ..= 120.~ 10-~ <br />Annul~.[Evahmtion of ~ge S y~t0nl . 75.~ 10.~ <br />~m~yr Truck hxs~.cfion, First ~ck ~0.~ <br /> <br />(Mark if Applicable to this Application) <br />( ) Test IIok!l are Dug <br /> <br />(~) 'rhl~ work will be p~rfia'med by a DEQ l.ieensed litstallet <br />( ) O~her <br /> <br />Site EYalualion, first Iol ~ $ 2~.~ ~20.~ <br />Site ~valuafion~ ~. addl. Io~ 165.~ 20,~j <br />~tan~d System 2~.~ 1 <br />Capping Fill 330,~ 10.(~1 <br />Gray WamiDi~al Sump 95.~ ~0,~ <br />Sa~'~iger 355.~ <br />Soepage Trench " 2~,~ 1C~ <br />$mep Slq~ k~.% 10,~ <br />~teradon 2~,~' i0.~ <br />Repair, ~a~ {tank) ~.% <br />Cons~fioa Penni genewM ~i*ld Visit) 120,~ 1O.~ <br />Cons~etion Petit Renew~ {No Fiq~d Vier) 70.% <br />Aafl~ofiv~fioa N~iee &ield Visit) i 120.~ 1O.~ <br />Aufl~otlvatlon N~c* ~o field visit) 70,~ 10.(B <br />Bxis~ag ~y~tem Evaluation l'~O.~ <br />~mml Eva uat oa/~l~mat w SyStem 120.~ "" <br />Annual Eva~fion~emp. of H~dship MH 75.~ <br /> <br />IToal $ <br /> <br />NAME OF APPLICANT (please prir),t): <br />SIGNATURE OF APPLICANT: <br /> <br />. ~- <br />DATE: <br /> <br />MC I$-74 REV 1/92 <br /> <br /> <br />