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Received By:~7~:¥ ,. 220 High Stmet NE i ;
<br /> Zoning Valida~iolz~- Salem. OR 97301 ~,;
<br />
<br /> ......... Code-A-Phone 558-7904
<br /> Ss'g-7948 A t0N 00UNTY
<br /> BIJILDINQ INSPK¢Y 0N
<br /> SITE EYALLTA?ION ~/OR ~EF?IC ~IT ~i~TION
<br />1. L~cation of Installatio~ ~ ) ~
<br />
<br />Job Add,ss I~ ~ ~ ~ T~ ACgt,No] ?O~'?/'~ Cross Steer
<br />I Subdivision ~
<br />Mobile ~ome Park
<br />
<br />:L~m~ctoLln~orm ation
<br />
<br />Properly Owner ~ ~ ~, Mailing Address:
<br />Autb, Ageal/f.~asee ~iling Add~ss: Phoa~ No,
<br />C~'gt'~ter~usinvss Nam* & Number .......... Mailing Address:
<br />DEQ Licensed Contmcter & No, · ~iliag Add~s~; Phone No,
<br />
<br /> ~SF - Daily Sewage l~i~w)
<br /> Site Evaluation~ fitst IO.0..O. 8;~!.,,,D$,F , 245,00 20.00
<br />Site Evaluationt ea. addL 500 ~al, DSF · , ........... 75,00 20.O0/m'
<br />Cap£ia~Fill S : 415.06..7: ' ! 10.00
<br />Disposal TrenChes in Sap...rp!.!~ 24L00 i 10.00
<br />Ora¥ Wate~ Waste Disvosa{ Sum~ 120100 ' 1,~.0Q'
<br />$.,9d Filget 445.00 10.00
<br />~¢~oa,,a Tenth 24S.00 lO.OO
<br />
<br /> ([Or each ~i!igD~l 500 gal DSF ~]0~., , .00
<br /> ,6~[e,¢,6oas 24~,,:,90 10.00
<br />
<br /> Coasl;m~tion Posit [e~wal (Field ~i"~it~) 150.00 , 10,00
<br /> Authorization :N6tke ~o Field Via!l}' 85.00 10,00
<br />
<br />(Mark if Applicable I ~ this Application} ) Test Holes are Dug
<br /> ) I will call when Test Holes Dug
<br />
<br />) I am performing work on a property I own or occupy
<br />) I am a registered builder or ( ) thc authorized repmsentatiw
<br />) The work will be performed by a DEQ Licensed Installer
<br />) Other
<br />
<br />MC 15-Si REV 2/93
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<br />Residential Sinele Family
<br />Site Evaluatlon? flint lot 245,00 20,00
<br />Sit* Ev*aluatioat~ea. Mall. lot. 205,00 20.00
<br />Construction permit, .
<br />Standard System 245.00 "16,00
<br />Capping Fill .... : 415.00 10.00,,,
<br />Disposal Trench in Sapxo j e ~4f,t)9 10,00,
<br />Omy Wa~t Disp,o aal S.u. mp 120.00 10.00
<br />Holding Tank 94L00 10.00
<br />Presmre Dist dbutlola 350.00 10.00
<br />_,.l~dgn~ant 245.00 I0.00
<br />Sand Filte,E' 44~,00 10,00
<br />,%epage T.,mns,h i 245.00 10.00
<br />Steep Slope 245.00 I.O.QO
<br />Tile Dewate6n~, ]50.00 I0.00
<br />Alteration .... 245,00 19.00
<br />Repair, Meier (drainlield} 115.00 .... 10.00
<br />R, pair. I~,or (tank) 75.00 10.00
<br />
<br />....Construction Permit Renewal (Field,,y s ) 150.00 10,09,
<br />Constmeti0n Pa~ t Rehewa (No F e d V ~ t),,, 85.00 10,00
<br />Authorization Notice (Field Visit} .... 150,00 I?.,00
<br />Authorization Notice (No Field Vi?it) 85,0q,,, 10.00
<br />Existing System Evaluation ,, 1~0.,00 10.00
<br />Annual ~..va! uation/Alte motive System,, 150.00 ,00
<br />..,A~n~al Evaluationfremp. or Har~hlp MH 90,00 .00
<br />Reval .Ama variance Site Evaluat,!on 245,00" 20.00
<br />
<br /> Total ~ ~,~ [
<br /> Receipt NO
<br />I agree to install according to ~he submitted plans and specifications, the laws
<br />of the State of Oregon and the o*:linances of Marion County.
<br />
<br />NAiVI_E_ OF~APPLICANT (please print):
<br />
<br />DATE:
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