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FOR OFFICE USE ONLY
<br />IZ,e~eiYed
<br />Zomng valiOatio¢- ~2~C.~ ,,,
<br />Date: I 1/~ t~./~
<br />
<br />MARION COUNTY: BIJILDING INSPECTION
<br />220 High Street NE
<br /> Salen~ OR97~01 . "'
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<br />Subdivision ~ ......... I ~,[~ i glo~k~ NO, ~mpIoyees
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<br />:tot Information
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<br />....~ ............................ . iling Addi.,'~ ........
<br /> p~pert7Own~r ::l:, i' Ma : PhbueNo.
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<br /> Auth, Agent/Lessee , ~}lins Add.ss: : Phon~ No. '
<br /> ~ont~ctor Bus'ness Na~ & Number "' '1[ '~lJng Add~: .............. Phone No,
<br /> D~ Li~en~dC0nt~tor& No, : ''
<br /> ;; i ~i[~hg Add.ds:: 2 ~one No,
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<br />Fees
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<br />Residential Single Familv
<br />Site Evaluation, l~rst lot 245,00 20,00
<br />a=~w~e:i~os~ Sump: mo,00 ~o.oo
<br />~nd Fil~r 445-00 10-00
<br />, gte~ Sl~e 245.00 10.00
<br />Tile Dem~n$ , 350.00 10,00
<br />Alt~mtio~ ' ' 245.00 10.00
<br />~pairt Maj0t (dmi~field) 115.00
<br />,, ~par. ~nor(mk}" · 75.00 10-00
<br />Construction Pe~it Ren~ (Held Visit) 150,00 10,00
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<br /> Authofi~tion Notice (~ield Visit) 150.00 10,00
<br /> Aatho~ati~n N0tiCe ~0 Field Visit) 85,00 10.00
<br />: ~ ~istlng Sy,~m ~valuaion ~ 15o.00 1o.00
<br />Annual ~valuatio~Al~maive Sy~m 150.00 ,00
<br /> A~ual ~v~uatlo~e~ oI H~shlg.~, 90-00 ,00
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<br /> · ' Receipt No,
<br /> I agree to in/stall accordimz to the submitted plans and specifications, the laws
<br /> ~ .~ ?,, j ::": oftheSm~fO~gon~dtheo~inan~e~0~doa~oun~,'''
<br /> ,,. . : , , , ,
<br />) T~t Hol~s a~ ~8 ,
<br />I will ~all wh,~ T~a Hol~s
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<br /> I am a ~gis~d build*r dr ( )~e ahthOfi~d ~p~i~V~ ~ ·
<br /> ~e work will be pe~ed by a
<br /> Other
<br /> SIGNA F~ OF APPLIC~: DATE:
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<br /> C~mcn-cial (DSF, Dailv '~l~wa~e Flow1 I
<br />,, $ te l~va uaiion, first IQ00 Sa): DSF 245,00 ,, 20,0,0
<br /> Site EvAluatiga~ ea, ~dl. 500 ~al. D~ .... ~,~;00 2D,o0/~
<br /> Construction & ~pair Petite
<br /> Standard System te,~s than I000 ssi. DSF 245.06 ...... 10.00
<br /> ~fidard Sya~ mom than 1000 ~1. D~: ...............
<br /> ~45.00 + $1 ~ o~h ~dl. 500 sal. DS~ I0.00
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<br /> ~my Water Was~ Dispo~l ,$u,mp 120.00- ' I0.00
<br /> Holdin~ Tank 245.00 I0.00
<br /> P~ssa~ Distribution ~60.00 ' 10.00
<br /> Redundant System ~45,00 10,00
<br /> ,~epa~cT~nch 245.00 I; 10.00
<br /> s~,p Slope :45.00 ~o~o0
<br /> Tile D~atedng Symem 350.00 10.00
<br /> >600 gal DSF~<1001 gal. DSF 100,00 ,00
<br /> (Pot e~h ~ditiona1500 8al. DgF 25,00 +00
<br /> Alterations ~,00 10.00
<br /> Gon~tmetlon Pe~it ~newal ~o Field Visits) 85.00 I0.00
<br /> ~isti~g ~7*tcm ~valuation ~poR I$0,00 10~00
<br /> Authofi~tiofi Noti(~ ~Field Visit) 150,00' 10;00
<br /> Annual Evaluation 9f&l~m~iy~ 8ys~m 1So,oo : 10,00
<br /> Au,nual ,~alu ~tig,u,,~ f,~c ,,Syatem 90,00 : 10.00
<br /> ~per Track In,teflon. Flint tmck ~0.O~ .00
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<br />MC 15-$1 REV 2/93
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