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FOI~ OFFICE USE ONLY <br />Redeived By; <br /> <br />Date: <br /> <br />MARION COUNTY BIJILD1]q'G INSPECTION <br /> 220 High 8~.¢t N.~ <br /> Salem, OR 97301 <br /> <br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br /> <br />1. Loeati0n <br /> <br />L DEQ Licensed Centractol <br /> <br />i Staml*rd gys~rn ~¢Ss than 1000~al, DSF 245.00 10.00 <br /> <br /> ,,,m,oo .... .,n-oo <br />] Hold~ Tank 245.00 10,00 <br />] ~u~ ~l~tn~utioo ~50,00 : I0~ <br /> <br />~~ ~4~.oo I <br />._~. 2~.oo z0.00 <br />.... R~p~} Mi~or 75.00 I0.00 <br />~y~ e~ Eva uatio~poa 150.00 : 10.00 ] <br />Authori~llon Notice (Field Vi*i0 150.00 ,10,00 <br />Annual Bvalua[[0~ of Altemativy System I 150,00 10,00 <br />Anfiual Evalua6[n if La~c Syatem ~0,00 <br /> <br />(Mark if Applicable to this Appllcatlol~) <br />( ) I will ~all when Test l~lcs Dug <br /> <br />8lt~ 2yalualioa~ ~mt lot[ ...... 245.00 <br />Gay wacr Disposal, S~ Ii0.00 I0~ ,,_ <br />,,?msm~ ,Dis~ution ~$0,00 10~00 <br />S~nd HRor . , 445,00 10.~ .~.-' <br /> <br /> R~r, M~j~L(dminfidg) Il [0'~ l <br /> <br /> ConStruction Pc~g ~en~wal ~eld ~is}t) 8~,~ 10l~ <br /> Rein~pcetlo~ Fee 25.00 <br /> Autho~ti~ No~¢e (~J~}d VJ~[0 150,~ 10.~ <br /> Aanual EvM~tio~Al~Kfivo ~$t~m 150,00 ,~ I <br /> <br />MC B-SI REV 2/93 <br /> <br /> <br />