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FOR OFFICE USE ONLY
<br />R~ceived By:
<br />ZonlngValidation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />
<br />8:00 a.nl. - 4:30 pm Phone 588-5147
<br />Code-A-phone 588-7904
<br /> PAX 588-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT .&PPLICATION
<br />1. Location of Installation
<br />
<br />Subdivision '~i~
<br />Mobile Hem, Park
<br />
<br />2, Contractor information
<br />
<br /> 'Hn d : /~ 'Pho O. ' ~
<br />Auth. Agent/Lca~¢~ Maihn8 Addi'a~: / Phone No. ~ ~
<br />'C htr ~r~u~aa ~&Nu r
<br />DEaLi¢~sed~oat~r&No. ~ ~ ~ ,honeNo,
<br />
<br /> Commercial (DSF - Daily Sewage Flow} /
<br /> Site Evaluation, first 1000 gal. DSP ~ 245,00 20.00
<br /> Con~tmctlo~ & Rep~ P¢~i~ '~ ",
<br /> Stan,d~rd, STst,em I?~s than 1000 sal. DSF ~, 24~.00 10.00
<br /> st~d~SY~!~ ~ th~n 1000gal. DSF:
<br /> ~ppi~$ ~ill .... X415.00 10.~
<br /> Disposal Trenches ia S~]ite ~5.0~, 10.00
<br /> Holding Tank 245~00 I0.00
<br /> ~odandan~ System 245.0~ 10~0
<br /> Sand Fil/e~ 445.00 ~ 10 00
<br /> S0~page T~nch 245,00 10.O0
<br /> Steep Slope 245.~, ,,,
<br /> Ti]~ Dcwatefing System 350.00 '~'I0.00
<br />
<br /> >~00 gah DSF~ < 1001,.~ ,.,DSF 100.00 < .00
<br />
<br /> (For each ~ditiona1500 ga[~,,~gF ,. 25,~0 ,00
<br /> Altemt;on~ 245.oq ...... 10.00
<br /> ~spair~ Mioor ......... 75,00
<br /> ~ns(~gtlo,n Petal/Rental (Fiold Visits} 150~00 10-00
<br /> Construction P~it ~newaJ~9 Field V s ~) 85.00 10.00
<br /> F~isting Sys~m Evalq~i,pn ~po~ 150.00 10.Q~~:
<br /> Autbofi~,}~,~p Notk~,(Fi~ld Visit) 150.00 10.00
<br /> Authorization Noti¢~ ~0 Field Visit} ........ 85.00 10.00
<br /> Annual Evaluation ofAl~mative Sys~m ~ ~9,.00 10.00
<br /> Annual Evaluation of~ SYstem 90.00 10.00
<br />...... ~umperTmeklnspe¢ on,~a add rock 55.00 .00
<br />
<br />(Mark if Applicable to this Application) ) Test lloles ate Dug
<br /> ) I will call when 'rest Holes Dug
<br />
<br /> I am performing work on a proper'fy I owe or occupy
<br />) I am a r~gisteted builder or ( ) lhe authorized ~prosenlatiw
<br />Thc work will bt performed by a DEQ Licensed Installer
<br />Other
<br />
<br /> Residential gin~le F~ui]Y ~ $
<br /> Site Evaluation~ fi~t lot 24~.00 ~ ~:
<br /> S[~ ~valu~ion. e~ ~dl, lot 20~06 20.00
<br /> G~y W~r Di,po~ Sump 120.00 10.00
<br /> Holding T~k 245,00 10.00
<br />
<br />~duadaat, 245.00 ..... [o,.00
<br />~tqe~Sl6~e "~ 245.00 10.00
<br />At~emloa 245,00 10.00
<br />Repair~ Ma{9,[ (dminfi,{ld) ILL00 ....... 10.00
<br />I ~ ~pair, Minor (~nk)~-' - 75.00 1o.oo
<br />~nstmc6o~mit ~newa}~,~, Fi~ld V sit) 85.00 10,00 ....
<br />~i~o fi Fo~ 2~.o0 .o0
<br />X~tion Nofic¢ (Fi~M'~ a t) ..... 150.00 10.00
<br />' Xuthofi~60i N~6~ ~o Field Viaj~) ....... 85.00 10.00
<br />~i~i~g System ~valuatioa 150,00 ~ ~
<br />Annual ~vMua0~Al~m~w S~,gm I~0,00 ~ ,
<br />......~,a,~ual EvMu~i6~¢mp. or H~dshJp.,~H 90.00 ,00
<br />
<br /> Receipt No
<br />I ag~e to install according to the submitted plans and specifications, the laws
<br />of the State of Of~gon and thc ordinances of Marion County.
<br />
<br />NAME OF APPLICANT (please print):
<br />S~GNATURE OF APP~.II~AINT: DATE:
<br />
<br />MC 15-SI REV 2/93
<br />
<br />
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