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<br />FOR CITY USE ONLY
<br />
<br />Received By: ~
<br />Zoning Validation' .. ;;
<br />Date: \.2... \\ .5
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />COMMUNITY DEVELOPMENT CENTER
<br />285 Church St, NE - Room 132
<br />Salem, O«gon 9730 I
<br />8:00.m-4:30pm Phone 588-5147
<br />24 hr, Inspeenon Line 588-7904
<br />FAX 588-7948
<br />
<br />SITE EVALUATION AND/OR SEPTIC PERMI
<br />1. LOCATION OF INSTALLATION '
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<br />Job Add"",
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<br />Subdivi,io,
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<br />Blook .1 L
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<br />S,"¡u, ø I
<br />Lot Width .$V
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<br />Tow",hip I,:;)
<br />LOt "opth 1(, 5'
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<br />R>ngo S I£.
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<br />:;;;:;;~~o, 3
<br />W,tc>: Supply,
<br />p""tow,n ( )
<br />Commu,ityWon ()
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<br />~:'J::"'::,No3
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<br />A".,
<br />
<br />Spring ( )
<br />City ~
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<br />Z, CONTRACTOR INFORMATION
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<br />A",h. Ago."L."",
<br />Co'"'cto,' ""'""," N"", Ii< N""'b" /-(¡tv.,,)
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<br />fr/<LS
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<br />IJ.~/""'f.
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<br />
<br />PhonoNo. <"'>.""1- J7Cy
<br />4>ho., No,
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<br />P'OP'"Y OW"'"
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<br />",4""",- d 6.4..,,/,. ",c.,!
<br />
<br />C-
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<br />dll.
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<br />"ho", NO, ?'-'-y - 3;> r "?
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<br />3. FEES
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<br />.. F." inolud, DEQ Sure"",,,' ($30.00)
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<br />Site EvalnnHon, Single Family Dwelli-w, first lot,............"""""""""""""".".."""""", ',::',,",',',',',',',',',',',.,',',',',',',',',',',',',',',',',','"",',',',,",,',",,"",,",,".'..",,,$,,32235°',°000
<br />Site Evaluation, Single Family Dwelling, ea addllot"""""...""..."..,....,... .
<br />Site EvaluaHon, Commercial, first 1000 gallo.. "..,................."...""....................,;............. ........."........"....320,00
<br />Site EvaluaHon, CommereiallOOO - 5000 gallon.... ..........""""""""""""""""..""...." ...320.00 + $9015001gai
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<br />Sit, Evaluation, Rural Area Variance.... , """"""""""""""""""""""":"',l... """"""""""""""""..""......,...320.00
<br />Construction P","it or Commercial Major Repair, first 1000 gaUons: '
<br />Stmdard System...................""""""..."""""""..."...", "......."""""""""""""""".., .............382,00
<br />Aerobio Sy,tcm"""",...""""""""""..,..... ................",..."....,.'"""""""..", ..........""""",218,00
<br />Capping fill System"""""""""."".......... """""""""""""""""" """""""""",593,00
<br />Ce"'pool..""""""""""""""""".... ".."...""""""""""".... .."""""""""".382.00
<br />Diapo,.1 T1'cneh in Saprolite"",.............. ....."""""""""""""',,,..,.. """"""""""".382.00
<br />Evapotran,pi...tion-Absorption System......",...""..."""",..",..""""".. """"""""""""..""" ".218,00
<br />G...yWaterDispo,al Sump "."",............ .."..."""...""""""""...... ...190,00
<br />Pn:"urn Disnibutiou System...... ..."""""""""""", """""""""""" .........553,00
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<br />"-edundant System.. .."""""""""""",.."", .........""""""""""""" ..........."""",382,00
<br />Sand Filter System.. """""""""".."".... ....""...""""""""""...."".............""""""""..,703.00
<br />Seepage Pit..""",................""""""""""""....",.. ..,...,..........""""",..",..".", ....."...""""""",..,..,312.00
<br />Seepage Trench""""""""""""".., ,.."...."""""""""" .....",,382,00
<br />Steep Slope""""""""""".............. """""""""""""" ......."""",382,00
<br />Tilo Dewatering System..... """""""""""""'......... ....""""""""""", """"""",,550,00
<br />Construction Pe,,"it or Commercial Major Repair, over 1000 gallons:
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<br />+ $100/500 gallons
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<br />~
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<br />Commercial Plan Review
<br />600 gallon,. 1000 gallo",..
<br />WOO gallons. 2500 gallons """
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<br />Commereial Minor Repa;r""""""",...................""",
<br />Single Family Dwelling, Minor Repair (tank only)".
<br />Single Family Dwelling, Major Repair (drainfidd) ..
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<br />Re,;dential Or Commereial:
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<br />Alte...';o"S""""""..........."""""""",...
<br />Pe,,"it Renewal, Field Visit""""".
<br />Pe,,"i, Renewal, No Field Visit"". """""""""""'...
<br />Authori..tion, Field Visit ............."""""""""..
<br />Anthonz..ion, No Field Visit """",.. ...."""""""".".
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<br />~~~: E~¡:;:J~:~~~;;;~'sÿ;;;;;;;:::: ::: ::::::::::::::::::::: :::::::1::::.....::::::::::: ::::: ::::: "...
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<br />Annual Evalua,ion TemponuyiHardship Mobi!e Home",.."....."...""""""..,
<br />Annuai Evaluation, Lorge System """"... ..."..""""""..", """'.."""",,.......
<br />Pump or Dosing Siphon"",.............."""""""".. ....""""""""",...
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<br />Pumper Truok I..peetion, First Vehicle """"".........."""""""..
<br />Pumper Truck In'pection, Eo Additionai Vehlclo """"""....
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<br />Septic Reinspectio" Fee.........."""""""""...........""""""..........""""""""....
<br />Septic ¡n,peetion for which no fee is specifically indicated.."""""""...,
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<br />Construction Pe,,"it fee + $251500 gallons
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<br />...,.........."..""""
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<br />.."""""""""",.... .."",,133,00
<br />,,133.00 +$25/500 gallons
<br />..173.00
<br />......130,00
<br />""""",210.00
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<br />....."""""""",..
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<br />....378,00
<br />.............227,00
<br />...."""",115,00
<br />"....247.00
<br />........"",117,00
<br />..........""",,247,00
<br />...."""""",,247.00
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<br />.....183,00
<br />..",123,00
<br />...25,00
<br />....,,67,00
<br />"",,40,00
<br />""",25,00
<br />40,~.
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<br />Rooe;p!:
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<br />Name of Applicant (Pleas" Print): ;!OJ]¿(,,- /...""YN~
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<br />Signatore of Applicant ~'~"""':"""':<:')'~
<br />MC IS." Red/9S
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<br />Test Hole, Ready: -,,-
<br />Da'e: --4.Lc /l/7~ TankPumped,_.
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<br />0,.
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<br />Do"
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<br />Pumping Certifieatio" Attaehed.- (Y) (N)
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