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.FOR (~FFICE USE ONLY
<br /> Received By:
<br />Zoning Valiclation
<br />Da~¢:
<br />
<br />MARION COUNTY BUILDING iNSPECTION
<br />220 Hig~h Street NE
<br /> Salem. OR97~01
<br />
<br />$:OO a.m. - 4:30 pm lraone 585-5147
<br />Code-A-Phone 588-7904
<br /> FAX 588-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br />__.~p. ge ~y Qw~OI~ ] Iv~llng Addmss Phone No.
<br />Jo~Add~ss ~[ ~"'~ (~ T~Acct, No, CmssStmet
<br /> I ~ Si~ No. U~ of Stm~u~
<br /> Mobile Home Park So~ ~ ~o, I ~o.
<br />
<br />........ ~,~idt~ , , ~t ~pth ............ Ae~s l~g. ~t Comer, ~,~t~ w~ ~nl ~
<br />
<br />2. Contractor Information
<br />
<br />PropeWy Owner ldsilinS Addi~ss: Phone No.
<br />Auth. Agcnt/Lea~c Mailing Address: Phon~ No.
<br />
<br /> Commercial (DSF - Daily Sewage Flow} ,~,
<br /> Site Evaluatio.n,t.,~i?~,Ioo0 gal. DSF 245.00 ,,20 PO
<br /> Site Evaluationr ea. addl. 500 ~-1,..I)~ 75.00 20.00/m
<br /> Standard Sy stem less than 1000 t~'al DSF. ........ 24~ioo 10.00
<br />
<br />~tqeP Slope ...... 245;00 10.PO.
<br />Tile I)~waterl!g System ...... 35.0..;.0~. 10.PO
<br />>oeo i~l. DSF,<~OOi"~a VSF t& 00 .PO
<br />
<br />(Forq,.a.¢b,additlona $OOga DSF .,, 25.00 .p~0
<br />Authoriza~ioti Notice (~ield visit) ,, 15o.oo lo.0o
<br />Authorization Notice ~qo ~!eld Visit) 8,5-OO 10.00
<br />Annu~!,,,Eva!uation of AIterna ye Sys. tem 150,00 10.00
<br />
<br />(Mark if Applicable to this Application) ) Test Holes are Dug
<br /> ) 1 will call when Test Holes Dug
<br />
<br />) i am a registered builder o} ( ) the authorized representative
<br />) 'Ibc work will be; perfotmeJd by a DEQ Li¢¢naed Ins~.lter
<br />)Other
<br />
<br /> Residential Single Family
<br /> site Evalu. at,ion, ficst lot 245.00 ' 20-00
<br /> ~ite Evaluation, ca_ addl. lot [ . 205-00 20.PO
<br /> Conatmetion permit .......
<br /> Standatd.,System ,~45.0~)' 10,00
<br /> Capping Fill 415.00 10,00
<br /> Gm}, Water Disposal Sump ..... 120,OO 10.00
<br /> H0!di~g Tank ......... 245.q.0,, 10.00
<br />Pressu~ Distribution ,,, 350.00 10,q,0
<br />Redundant 245,00 10,OO
<br />Sand Filter 445,00 10.00 ...
<br />~pagc Trench 245-00 10.00
<br />~_~teep Slope .... 24.~t~)0, 10.PO
<br />Tile l~waterin$ ....... 350.00 .... !0.00
<br />Alteratio~ ..... 245.00 10.PO
<br />.R~pair~ I~jor (drainfield) 11 $.OO .... 10.00
<br />.., ,~.~pair. Minor (tank) 75.00 10,00
<br />Constmction Permit Renewal (Field Visit~ 1 $0.00 10,PO
<br />Construction PcrmiLgonewal {31'o Field Visiti .85.00 10.00 ......
<br />· ,Reinspect on Fee 25.0Q,, ,00
<br />Author'-at,on Nofiqe {Field'Visit) 150.00 10,oo
<br />Authorization Notice (No,,Eie d V s t) ~S.00 10.00
<br />Existing System l~valuation 150.OO ,,, 10.00
<br />Annual Evaluation/Alternative S~,tem 1 $0,OO .00
<br />.... A,nnual gvaluationtTcm?, or Hardship MH 90,00 .00
<br />Rural A~a. yafiallee Site Evaluation ,, 245.~' 20.00
<br />
<br /> Receipt No.
<br />I ngrec to install according to thc aubmitted plans and specifications, the laws
<br />of the State of Or,gott and the ordinances of Marion County.
<br />
<br />NAME OF APPLICANT (please print):
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />
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