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FOR OFFICE_U?.E. 9b]L .Y
<br />Received By: "~//I/I/lJ~9'?'~
<br />Zoning ValidaJion ~
<br />
<br />............. Cod~A-Phone~VAX $88.794858S'7904
<br /> SITE EVALUATION ~/OR SEP~C ~E~ ~ON
<br />i. Location oflflst$ Ilatlon ~,~ .
<br /> '
<br />
<br />liro~e~; ~di ............................. M*iling Addr~s,s: Phone No.
<br />Auth. Agenl]Leaaec Ivlailing Add,ss: ~ooe ~o.
<br />Co~t~tor Business Name & Number Mailing Add~sa: phone No.
<br />DEQ LicenSed ~ntmctor & No, Mailing Add~=: Phone No,
<br />
<br />Fees
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<br /> f20m mer. eial CDSF - Daily Sewa*,e FLOW) $
<br /> Cons/mc/ion & Repai~ Pe~its
<br /> ~24~.00 4. $15 each addl, 300 gal DgF "10.00
<br /> Disposal ~nehe~ in Saproli~ ~45,00 :,, 10,00
<br /> Gray Water Was~ Bispo~l Sump, 120.00 10.00
<br /> Holding Tank I245.00 10.00
<br /> Pressure,DistributionI 3fi0~00 10,00
<br />Redundant System 24~,00 10,00
<br />~d Filter 445.0~ 10.00
<br />Sl~ Slope 24~.00 10.00
<br />Plan Review
<br />(For e~h additional 500 gal, DSF ~,00 '.~
<br />Conslm{tion P*~it ~n~[ (Field Visits} ,,, 150,00 10,00
<br />~9n${m~tion Pe~it ~newal ~o Field Visit} 8S,00 10,00
<br />F~istlng System Evaluation RepoR 150,$0 I0.00
<br />Authod~ion Notice {Field VisiQ 150,00 10,00
<br />Autho~tioa Notice ~o Field Vlsi0 g$,~
<br />Annual ~valuatlon.gf hlte~atlve Sy~em,. 1S0.90 , 10.00
<br />Annual Evaluation o~,~ System 90.~ I0,00
<br />~mp~r T~ck Inspect Oat ca, ~d t~k 35.00
<br />
<br />) Test Holes arc Dug
<br />) I will call when Teat Holes Dug
<br />
<br />) I ltm performing work on a propeay I own or occupy
<br />) I am a registewd builder 6r ( }lheauthorizedreprcsen~tive
<br />) The work will be performed by a DEQ Licensed Installer
<br />) Other
<br />
<br /> llesidential Single Family
<br /> Site l~valuation~ first lot 245.00 I 20.00
<br /> S ~ ~valu~.iont ¢g ~dL I~t 205.~I 20.00
<br />
<br />Standard, Sys~m 245,~ 10,00
<br />Capping Fill 415,00 10.00
<br />~o~l ~nch in $ap~lj~ 245.00 10.0O
<br />~plding T~k 245,00 10,00
<br />~s~n Distfibation 350,00 10.O0
<br />~dundani 245.00 10,00
<br />~epa~ Tm~ch 24fi,00 10,00
<br />~eep Slope 245.00 10.00
<br />~onstmction Pe~it ~newal (Field Visit} 150.~9 10,00
<br />~nstmction ~it Renewal ~9 Field Visit} 85.00,, 10.00
<br />~inspgction Fee 2~,~ .00
<br />Amho~fion Notice (~[d{ Vis~) 1~0,~ 10+00
<br />~isting Sy~m ~nluation 150.00 ~0.00,
<br />Annum Evalu~oWAl~m~ive ~7~m 150.00 .00
<br />~1A~a V~?ncc Si~ Evalu~ion 245.00 2~.00
<br />
<br /> Receipt No.
<br />I a$~0 lo install ac¢ordinS to ~c aubmlt~d plans and specifications, the laws
<br />of the $~te of Oregon and the o~inan~ea of~fion Count.
<br />
<br />MC 15-,ql REV 2/93
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