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FOR OFFICE. USE ONLY
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<br />MARION COUNTY BUILDING INSPECTION
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<br /> MARION COUNI'¥
<br /> uA rION mNO/O Sm'TZC LZCA ON DUILDING INSPECTION
<br />1, Locad*a ~f lnstallafi~
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<br />_2. Contractor In.fprmati0n
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<br />DEQLicenscdConttactor&No. 8erndt-Emerson Excav.
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<br />~mmercial (DSF -"Daily Sewaae l~low)
<br />Evaluation, first 100,0 gal. DSF ,, , 245.00 '20.00
<br />S~ite Evahiation. ca. addk,,500 gal DSF 75.00 20.00/m
<br />Construction &,Repair Pc~its ,,,
<br />_,,5,[andard System I~s~ than I000 gal, DSF 5~.00 10,00
<br />Standa~ Syste~,,mot~ than 1000 ~I. D~:
<br />~245,00 + $15 eaqh addl. 500 ~1. ~SF 10.0~'
<br />Disposal T~n*h~ in Sapm'ii~ 245.00 10,00
<br />P~a~um Distribution 350.00 10.00
<br />gedl ndan ~m 245.00 1~,.00
<br />San0 Fi[~;; ~,99 1q.oo
<br />Seepage T~nq~ ....... 245.00 ,,I0.00
<br /> Steep Slope ,,, 245.00 10,00
<br /> Tile Dcwatefi~ System ,350.00 IQ.00
<br /> ~60t~ g~L DSF,~'I001 gal DSF .... ioo,~9o .oo
<br /> (~pr each addition3,1500 g~ DSE ~,00 ,00
<br /> Consemctwn Pe~t Reoewal (Fmld Vmts) 150.00 10,00
<br /> Autho~zation Notle~ (Field Visit) , 150.00 10.fi0
<br /> Annual Evaluatlo~ of La~e System 9~,,~ t0.~
<br /> ~m~,er Twck Inspeetion~ Flint track ,, 50.0,0 .00,
<br /> ~mvet T~ek In~qefioa, ea. ~1. track 35,00 , .00
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<br />(Mark ffApplkable to this Applicalioa)
<br />( ) Test Hol~s are Dug
<br />( ) I will ~all when Test I'Iole~ Dug
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<br /> gm a iegistemfl builder or ( ) the authorized l~prcsentative
<br /> work will be peWo~ed by a DEQ Licen~d Ias~ller
<br />O~bcr
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<br />~a~sg~d~i': Vale Garden
<br /> Rd. L~'rlby ~ OR 37
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<br />Fhon~ No. 266-7223
<br />]i7
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<br /> 'Residenlial Single Fhmil¥ $
<br /> Site Evaluatiom first lot ,245,00 20,00 .....
<br /> Site Evalu~ion, eta. add!,, [~"~' ' 205,00 20,00 ....
<br /> Constm?tiou permit
<br /> Standard $¥steBl 245.1)1) 10,00
<br /> Capping Fill , 415,00 [9:00
<br /> DJ~oosal Trench in Sar. rolJ~(e 245.00 10,00
<br /> Gray W.ater Disposal Sump 120.o0 10.00
<br /> Holding Tank 245,00 ~9.00
<br /> pressure Di~.ribution 350.00 lO,OO
<br /> Redundant 245,00 10,00
<br /> Sand Filter 4~5.00 1,9,.00
<br /> ~cpage Trench 245,00 10.00
<br /> Steep SI,ope 245.00 10.00.,,
<br /> Tile D~wat?bg 350,00 i0,00 ....
<br /> 81temtion 24§,00 10.00
<br /> gepa!r~ Major (drain';Id) 115.00 I0.00 ,,,
<br /> Repair. Minor (tank), 75-00 10.00
<br /> Construction Permit Rencwal,,,(Fi¢ld VisitI ,, 150,60 ,, 10.00
<br /> C_o. pstmetion Permit Renewal ¢qo Field Visit) $5,09 10,00
<br /> R~inspeption Fee 25,00 -00
<br /> Authorization Notice (Field visit) 150,00 19-00
<br /> Aglhofi~atlon Nptiee (No leield Vi~it) 85,00 lO.00
<br /> ~;xistitlg System Evaluation 150.00 10,00
<br /> Annual l~v aluat io n/Alt.~ marly? System 150.00 .00
<br /> Annum Igvalustioa/Tcmp. or Haadahip MI-I / 90.00 ,00
<br />L,RugalAreaVarlanceSitegvalualioaI 245.00 20.O0
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<br />Total $ 255.00
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<br />Kee¢ipt No.
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<br />NAME OF APPLICANT (please l~nt).:
<br />SIGNATU~OF ~PLIC~: DATE: /
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<br />MC 15-S1 REV 2/93
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