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FOR OFFICE USE ONLY
<br />Received By:
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />220 High .Ya:m e t NiB
<br />~lem. 0R97301
<br />
<br />$:00 a,n~ - 4:30 pm Phons ~88-5147
<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 />, ,,I~OE¢3W (~voei [ Mailing Addrcr~ Phone No.
<br />
<br /> Subdivision [ ~ ~ ~ ~ ~t Block N , Em loyola
<br />
<br />2. Contractor Information
<br />
<br />?mpcay Owner Mailing Addrass: Phone No,
<br />Auth. Agcnt/L~aaec Mailing Address: Phone No.
<br />DEQ Liccn~d Cont~r & No. ~iling Add~: Phon~
<br />
<br />Comm~gF - Dailw.%wage Flow}
<br />Site Evalu~ion~ first I000 gaI..,D..~.F, ............ 245.00 20.00
<br />Co~astmction & Repai~,~,R~'
<br />S~nd*~ Sys~m less than 1000 gal'. DSF 245.00 i0:08
<br />S~ada~ Sys~m mom than 1000 ~al. DSF: ............
<br />$245.00 + $15 ~ach MdL 500 ~l- DSF 10.00
<br />...... ~]~Ei~ Fill 415.~ 10.00
<br />Ho]ding Yank ............... 245.00 10.00
<br />P~ssu~ Distribution ~9.00 10.00
<br />~pag~ T~nch ....... 245.00 10.00
<br />5tc~ 245.00 10.0~
<br />Plan ~vi~w
<br />> oo ............ .on"
<br />
<br /> (For ~auh ~,~,i{,{~na1500 8al DSF 25.00 ,00
<br />
<br />~nstmction Pe~it Renewal (Fiel.~,,~,isi~) 150.00 10,~
<br />Constmcti~o,?E~ t Ren~ ~o F ~ d V s ~) g~,-00 , 10.00
<br />~istln8 Sy~m Evalu~.~,n Rgpoa 150.00 ..... 10.00
<br />Auiho~0oa ~oficc (Fidd ~i9 150.00 lq:00
<br />..... Agthodgatlon Noti~ ~o Field Visit) ........ 85.00 10.00
<br />Annual Evaluati~ 9f Alternative Sy~m ,~$0.00 10.00
<br />.....~nnual Evaluation of~ Sys~m ,, , 90-00 10.00 ......
<br />~n~r Tack Inso~ctlon. Fist tack ~.00 .00
<br />~mpvr Tack Inapcc/~.ntea ~d ack 35,00 ...... ,00
<br />~her
<br />
<br />(Mark if Applicable to this Application) ) Test Holes ar~ Dug
<br /> ) I will call when Test l~olos Dug
<br />
<br />) I ara pe ffotming work on a property I own or occupy
<br />)lomat~gist~tedbuildcro~( ) the authorized mpr~senta0ve
<br />) ~e work will b~ pvffo~vd by a D~ Li~cn~d Ins~ilcr
<br />
<br /> Residential Single Fa.l~jJy ........
<br /> Sit~ Evaluation, first 19.1' ...... 245,00 20,00
<br /> ~t~ ~valu~ion, ~ ~dL lot / 205:00 20.00
<br />
<br /> S~nd~rd Sys~m ; "~5,00 10,00
<br /> G~ping Fill ......... 415.00 10.00
<br /> ~y ~r Dispo~l Sump ......... 120,00 10,00
<br /> Redundant 245.00 10.00
<br /> ~d Fil~r ~5.00 10,00
<br /> ~cp~ T~nvh ........ 245,00 10,00
<br /> Air,ion 245.00 10.00
<br />~pairr Major (d ~{n~e]d) .... 115.O0 10.00
<br />., ~pmir. Minor (~uk) 75.00 10.00
<br />Construction Pe~t ~newal (F{~ ,yisit) 150.00 10.00
<br />Construction P~it ~ne~9 Fi~ 8 V s t} 85,00 10,00
<br />Autho~tion,,~oti~e (Field Visit) 15~:~ 10,00
<br />Autho~ion ~pfie~ (No F e d V a t) 8~qO 10,00
<br />~in~ Sy~m,Evaluation 15~00 10.00
<br />.....~nnual Evalu~io~mativo S~m ..... 150.~
<br />Annusl Ev~u~o~a~p. or H~shlp MH 90,00 ,00
<br />~l A~a V~an~a Sits Eva}~0n 245.00 20,00
<br />
<br /> IO:c~ipt No,
<br />I agree to ina/all accolMinS to the ~b~tted plans and specifications, tho law~
<br />of the S~ of O~sou and the oMinan~ms of~don ~unty,
<br />
<br />NAME OF APPLICANT (please print):
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />
<br />
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