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· FOR OFFICE USE O~LY <br /> Received By: ~ <br /> Zoning Vali~tion ~ <br /> Date: / /2~--~/'~"q~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 Hish ~4~eet NI~ <br /> S~lem, Oll. 97301 <br /> <br />8~0 ~m.-4:30 pmPhone 588.$147 <br />Code-A-Phone 58S.7904 <br />FAX588-794S <br /> <br />RECEIVED <br /> <br /> F£tB 0 2 1995 <br />MA/lION COUNTY <br />BUILDING INSPECTION <br /> <br /> SITE EVALUATION AND/OR SEPTIC P~RI~IT AP~r~L, iCATION <br />1. Location of Installation f3z, J-~. ~, ~ ~P~ 7~ ~ <br /> <br />2, Contractor Information <br /> <br />Property Owner Mailing Add~s~: Phone No. <br />DEQ Lie~,~d Contractor & No.f ~ ~ ~F ~ ~ling ~d.s$: ...................... ~ouc No. <br /> <br />.~.~nm ere'mi fDSF - Daily Sewate Flow) ..............$ <br />Sit~ Evaluation~l- DSF 75.~ 20,~m ........... <br />Standa~ Sys~0'g~l, D~ 245.00 <br />Standard Sy~m mo~ th~ 1000 Ssi. <br />Capping Fill 4,[~,790 1~0 <br />, ,,~mY Water Waste Dispo~l Sump 12Q,~ ....... <br />Pmss~,~,st~bufion $50,00 I~,0Q ............ <br />Steep Slope ~ 245,00 10~00 <br />Authodzatlon ~otlcc (~icld Visit) 1 ~0,00 10,~ <br /> Aatho~zatlo~ Noticc ~o ~i*ld VhiQ , ,, 85{~ ..... 10.00 <br /> Annual gvalualio~ of~e Sys~m ~,00 ~0,~ <br /> ~mper Track I~ection~ Fi~t track I ~0.00 ,~ .................. <br /> <br />(Mark if Applicable to this Application) ) Test Holes at~ Du8 <br /> ) I will ~tdl when Te~t Hotea Dug <br /> <br /> ) I am pcffonnlnS work on a pmpeay I own or o¢c~upy <br /> ) I am a registered builder or ( ) the authorized representative <br />( ~ ~e work will b~ pcffo~cd by a DEQ ~cen~d Ins~ller <br />( ) Other <br /> <br />Residenii~i Single Family s <br />sit~ ~v~iugio~i, e~ ~dl, lot 205.00 ~o.o0 <br />~ction pc~it <br />S~da~ $y~em 245,00 10.00 <br />G~y W~r Di~o~l Sum~ ~20,00 10.00 .................... <br />Ho d n8 Tank ................. 245.~ 10,O0 <br />P~asu~ Diafibm~Rn ............. 350.00 10,00 <br />Redundant ................. 245.00 10.00 <br />~nd Filer ~ (' ~ ~5.0~ lO.O0 <br />~le ~wn~n8 ~ 350.00 10.00 <br />AltemSon 245.00 10.00 <br />~ns!~etion~e~it ~newnl ~o Field VieR) 85.00 10.00 <br />~u~o~ion ~oti~ ~o ~idd Vi~t) 85.00 10.00 <br />Aanu~ Evalu~o~Altem~ve Sy~m 150.00 ,00 <br />~nuai ~v~u~o~e~. or H~ship ~ 90.00 .00 <br />Ru~ Ama V~ce Site EFfuSion 245.00 20,00 <br /> <br />I sgxee to ml~t~ll ~ecoldmS to the mthm]Red pl~ <br />of the State of On:goB m]d the ontinances of Marion County. <br /> <br />MC D-SI REV 2/93 <br /> <br /> <br />