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<br />. FOR-CITY USE ONLY
<br />Rec:lved By: ~
<br />Zoning Validation: +;
<br />Dale tf- Z-i -"tS-
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />COMMUNITY 'DEVELOPMENT CENTER
<br />285 Church St. NE - Room 132
<br />SaJem, Oregon 97301
<br />8;ooam"¡;30pm Phone 58&.5147
<br />24 hr.l""pection LinE 58&.7904
<br />FAX 588.7948
<br />
<br />Cis- \(01 Y
<br />
<br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />I. LOCATION OF INSTALLATION
<br />""'P'"yOw"" Y.<:.65'-AL/Cõ ;t/¡'6!Jh
<br />~
<br />/3...o#J
<br />
<br />
<br />
<br />81"-;'" ( )
<br />City
<br />
<br />S,,"lon 0 2. Town,hlp /0 !Ii
<br />,-", WI"th 0 '-"m.p" .:?:?~
<br />2. CONTRACTOR INFORMATION
<br />P"'I""yC)wn" ....(Y<:"&<t ALleb
<br />Amh.Ag,"tILe""" C .AMIP~
<br />Con""to,B",ino" N.",o & Numb<" CfiAfP%(1..¡.bM6.$,
<br />
<br />
<br />3. FEES
<br />
<br />" F,., Ino1udo DE<) Su",h"..
<br />Sit. Evnluation, Sin~lo FaIDily Dwolling, fitst lot""""",,-
<br />Silo Evaluation. Single Family Dwelling, ea addlloL.."""""""....
<br />Silo Evaluation, Com",ercia!, fitSt 1000 gallon, """""""",..
<br />Site Evuluation, Comme",iallOOO . 5000 gallons """""
<br />Site Evaluation, Ruml Are. Variance".......".""""".,......
<br />
<br />Con"ruet;on Pennit Ot Co""",,cial Majo. Repait, fitSt 1000 gallon"
<br />Standard System"""...... .. .""""""",...
<br />Aerobic System"......."""""",...
<br />Capping FiJI SyStem,."""""".
<br />Cesspool"""""".........""""",,-
<br />Dispo..1 Trencb in Saprolite......"""""""... """""""".."""..""........
<br />Evapotranspinttion-Absotption System.."""""""""" ..",.."""",.
<br />a,ay Watet Di,posal Sump """""."........"""",......~"""""",:
<br />Holding Tank (Commerciai only)_""""""".""""",:""""
<br />
<br />P""'u'" Distribution System"""""",..."""""""".."""""""",....""""""",
<br />Redundant System .........."""""" .."""""""..."""""".""
<br />Sand !'illor Sysrem"""""""
<br />Seepage Pit""""""..
<br />Seepage Trench ".
<br />Sleep Slope........ ".....
<br />Tite Dewatcri1>g Sy'tem". "'" """"...
<br />
<br />C""'J1Ic<lon Perm;1 '" Commem;,,/ Majo, Rep.Ü" Om 1000 gallons;
<br />
<br />",'
<br />
<br />",.....$325,00
<br />.."""",240.00
<br />.....325,00
<br />........."",,325,00 + $100/500 galions
<br />""""""",325.00
<br />
<br />..""""""""""""""""""
<br />
<br />.."""",387_00
<br />""""""...223.00
<br />."""""""....59$,00
<br />"""""""..,..387,00
<br />.......,,387,00
<br />"""""""""...""",223,00
<br />""""""",,195,00
<br />"....,,387,00
<br />"""""",,555,00
<br />......387.00
<br />.""",708.00
<br />.",,317,00
<br />.""",387.00
<br />.....387,00
<br />"""..555.00
<br />
<br />Comm"cial PI"" Roview
<br />I~gg~~¡~~: :1ggg ~~¡~~:::::::::::'::::::::::::::::::::::::::i::"", "
<br />
<br />Commoreial Mino< Ropal,....."."",............""",........
<br />Single Family Dwelling, Mi,", Repair (tonk only)...
<br />Singlc Family Dwelling, M'jo.- Rcpair (d.-ainfleld) "
<br />
<br />Re,idential Or C"",memi,';
<br />
<br />Allceation,....."""",....."."""",
<br />Ponnlt Renewal, Field Vi,iL""",
<br />rermit Renewal. No Field VlsiL
<br />Authorization, Fidd Visit "......"
<br />Authorizatinn, No Fidd Visit "'"
<br />
<br />Existing System Evaluation """"""""...""""""".....""""""""..""""""
<br />Annuai Evaluation/Altcmative System""..""""""",."""""""".
<br />Annual Evaiuation TempomylHard'hip MobilelJome"",.
<br />Annual Evaluation, Larg<: System ..""""".... """"""""""""""""-"""""",..
<br />Pump Ot Do'ing Siphon"
<br />Pumper Truck Inspection, Fitst Vehicle......""""...
<br />Pumper T,,'ck In'rcetion, Ea Additional Vehicle"
<br />Septic Rein'p<ction Foc""",........."""".........""""........""""".
<br />Septic In'pootion 10< which no fee is specifically Indicated".
<br />
<br />Construction rermit Fee + $25/500 gallon,
<br />
<br />.."""""""",...""""",133,00
<br />""""'"",;".."""",,133_00 +$25/500 gaJlon,
<br />..178.00
<br />...t35,00
<br />",215.00
<br />
<br />Namc 01' Aprlleam (Pto"e P~; ;7.~""6.s
<br />
<br />S'gn",urc 01 Applicant: ~--
<br />MC 15-51 R" IN!
<br />
<br />Date: ..¡. -/ ¡L ~9 -C Tank Pumped:
<br />
<br />...383.00
<br />......,,232,00
<br />.."""",,120,00
<br />....,,252,00
<br />""",,122.00
<br />"".....,,252.00
<br />""""""",.252,00
<br />.."",,188.00
<br />.",128,00
<br />...25,00
<br />...102.00
<br />"..40,00 - ..fL "
<br />¡~:gglh~~ ~;1~
<br />
<br />R"o¡ptr 1';t32-';I;<J.< Tot"I....:;L-J../.......6d2 ¿'13,'1Ô
<br />Te" Hole, Roady: N/ A
<br />'f-I/:>"'9¿.-
<br />
<br />757 nn
<br />
<br />D,~
<br />
<br />PumDin. Certification Attached: IY\ IN!
<br />
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