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FOR OFFICE USE ONLY
<br />Received By: ...
<br />Zo~ingValidatio~ __
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br /> ·dem, OR 9730 !
<br />
<br /> - 4;~0 pm ~hone 588-5147
<br />C~de-A-Pbol~n
<br /> FAX
<br />
<br />,$1TE EVALUATION AND~/~)~_.~J~PTIC pERMIT APPLICATION
<br />Width i $ ] .......
<br />
<br /> 3. Fees ,,,, ~ ~ v= .....
<br />~e, ew~_~Fl~w') ...... ,,,,,,, $ Resid~nfi~i Single Familv ....
<br />
<br /> Sitz l~v~lu~rst 1000 8al. D!;lF 245.00 20,00 Sit~ ~uaiion, first lo{ [ 245,00 '--~,00
<br /> s ~ Ev .~tlo~, =a. ~l. ~0,~ ~.~,i,'bsF ?d:0o :~o.occm slt~ ~v,hmlon, ~ ~, lot I ~.00
<br /> CohstmCtiO~ & Re, air Permits .... __ . . ....... Co~?truetloa perrnlt ,,
<br /> S{aodaM g~gtem les~ thtm 1000 ~al. DSF 245.00 10.~ 8~ ~m . . ~
<br /> $~nda~ ~stcm mo~ Ihan I000 ~, D~: C~RhR ~11 .... ~15.00 10.~
<br />
<br /> ~?P!n Fill 415.00 10.~ GnyW~Su~p ,,, 120.~ 10.~
<br /> G~y Wa~r Wag~ D~g~ml Seep ,,, 1~0.~' ,, ~O.00 P~ Di~dbut{o~ ...... 350~ 10,~
<br /> Roldinfi Tan~' 245.00 I0,00 ~do~,~l ~45,00
<br />
<br /> ~od~odaat Sy$~m . ~$.~ 10.~ ......... ~a~ T~R¢~ .............. ~,~ 10.~
<br /> ~nd Filter ~,~0 10.00 ~ ~o~e [, ,~a~ 10.~ ,,,
<br />
<br /> ~c ~w~tcdn~ Sys!~m 350.00 ]O~., ~pair, M~JOt ~dniafield) 115~0 10.~
<br />
<br />~a~ ~{I ,~q) ~n~metion Pe~it Renc~{ ~o ~ld YisJ0 gS.~ 10.00
<br />(For c~h ~dtgonal 500 gal DSF 25.00 .00 ~in~eot}on Fee ............... 25.00 ..... .00
<br />A~tc~6on~ 295.00 ~ t0.00 Aotbog~ioa Noticm ~igld Visit) 150.00 10-~
<br />K~pair~ Minor ........ 75,~ ,1~,~,, Authod~n Notice ~o FieM Vigil} 8~,~ 10.~
<br />Cofl~tmc onPe~ Ren~m},,,,(,FieldVis/~) =~0,~0 10~0 ~;~tl~ggys~m~val~ion 150.~ 10~
<br />~slm~ion p~it Renewal ~o Field Visits) 85.~ I0,~ Aq?~l ~valua~d~m~ $~gicm ,,,! ~,~ .00
<br />~a/Jng SyMcm ~valuaioa R~9~ 150.00 I0,00 Annu~ ~aluaio~cmp. oz ~ship ~ 90,~ .00
<br />Avthofi~ti0n ~ti~ (~ld Viii0 150,~ 10.~ ..... Ru=l Asa V~n~ ~tg ~v~uaioa ' ~'45.00
<br />~iho~tion Notice ~o ~eld Vi$~) g~,00 10,~
<br />AonUM ~Vg!ua~i~n of Al~m~ve System 1 $0.~ 10~' ]
<br />Aup~l Evaluation of~ Sys~m p0,~ ......... 1,0~
<br />
<br /> ~her
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<br />(Mark if Appllelble to thi~ Application) ) Test Holes are Dug
<br /> ) I win call whe~ Te~ Holes Dug
<br />
<br /> am peffo tuning work on s pcopcgy I own or oc~py
<br />) I am a ~gigemd builder 6r ( ) ibc aUthOred ~pmsgn~gw
<br /> work will be peffo~ed by S D~ Licensed ~ller
<br /> Oth¢~
<br />
<br />NAME OF APPLICANT (p~¢ase print):
<br />
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />MC I~-SI REV 2193
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