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2. Contractor Ioformntion
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<br />Contva~c-t~TEus~iness Name & Number ...... Mailing
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<br />3. Fees
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<br />Site Evaluatlon~ ea. addl. 500 ~al. DSF 75,00 20,00/m
<br />Constmc,ti~E..&.g~pair Permits
<br />Standard System le*~ than 1000 gal, DgF ........... 245.00 10.00
<br />Sts.dard System mo~,t~ ,!p~.0,,t~. DSm
<br />g245.00 + ~5, 9~.,~,~1, 500 ~1, DSF 10,00
<br />Disposal Tg~ehes in ~p~lite , 24~.90 ......... 10.0o
<br />Gray Water Waste Dispo~l Sump 120,00 10,00 .....
<br />Holding Tank 245,00 10-00
<br />Seepage T~neh 245.00 10.00
<br />Steep Slope ............ 24~,00 10,00
<br />Plan Review
<br />R~pai6 Minor 75,00 10,00
<br />Construction Posit R*aewal (Field Visits) ~ 1 $0,60 10,00
<br />Construction Po~it R~n*wal ~o Fidd Visiu) 85,00 10.00
<br />Auth0fi~tion NotiCe (Field Visit) 150,00 10,00
<br />~nnua~ gvaluatlon of ~ltem~ive S~$~m 1S0,~ 10-00
<br />Annual Evaluafipn,,q~r~ ,S~,m ..... 90.,00,~10-00
<br />Pumper Track Ink,etlont Fi~t track 50.00
<br />(Mark if Applicable ~ this Annlicatlon~
<br />
<br /> Resi~'~ntial Sinnle Family
<br /> Sit~ Evalua~ion~ fira~ lot 245,00 20.00
<br /> Si ,~.,,}Zvaluationt ea, addl. lot 205,00 20,00
<br /> COnstra¢tion permit
<br /> Stands .td...=Systsm 245-00 I0,00
<br /> C.~ping Fill 415,00 10.00
<br /> DimoaalTwnchinJ.%orolite ~45.00 10.00
<br /> Gray Water Disposal Sump 120.00 10.00
<br /> Holding Tank 245.00 10.00
<br /> Pressut~ Distribution 350.00 10.00
<br /> Redundant 245.00 10.00
<br />Sand Filtsr 445.00 10.00
<br />P~epag~ Trench 245-00 10,00
<br />__Steep Slope 245.00 10.00
<br />Tile D~wateiing ~50.00 10.00
<br />Alteratlo~ 245.00 10.00
<br />Rep~irl Mai0r idrainfield) 11~.00 10.00
<br />Repnlr~ Minor (tank) 75.00 10.00
<br />Constmctlon Permit Renewal (Field Visit) 150,00 t0.00
<br />Construction Permit l~:newal (No Field Visit) 85.00 10,00
<br /> , Retartmetimt Fe* i 25.00 .00
<br /> Authorization Notice (Field Vis!~) ..... 150,00 10,00
<br /> Authorlzatip, n,,~o~ige,(No F e d V s t) 85.00 10100
<br /> Existing S~Ate,m Evaluation 150,00 10.00
<br /> Annual Evaluation/Alternative $},st~,m ,,, 150.00 .00
<br /> Annual Evaluation/Tem. p,c, 9,r Ha~d~hlp MH 90,00 .00
<br /> Rural Area V~lfia~.,~,~it~,Pva}uatlon 245,00 20,00
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<br />Total
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<br /> · State of Or~gon and the O
<br /> )Test Holes a~. Dog
<br /> lwill call when Te~t Holes Dug
<br />
<br /> ( ) i am p~ffoming work on a pmp~ay I own or occupy ~ ~]02~,~ OF AP~LIC~ (please print):
<br />
<br /> ( )'l~e work will be peffomed by a D~ Licensed InsUller 1~8~ / ~ ~ / ~ ...........
<br /> ( )om~ ~'-~'CX L ~ ~ °e~¢~/0~I GNAT~ O f m P LI C~: 7V~' e~DATE:
<br />MC 15-SI REV 2/93 O~
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