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FOR CITY USE ONLY ReCeived By: __ Zoning Validation: Date: MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St. NE - Room 132 Salem, Oregon 97301 8:00am-4:30pm Phone 588-5147 24 hr. Inspection Line 588-7904 FAX 588-7948 SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION 1. LOCATION OF INSTALLATION Subdivision ~,~/~ Section ~'~O 0 [Township Lot Width ~,~ I I tDepth 2. CONTRACTOR INFORMATION Acres ~2, ~ Mailing Addmsst~,o~ ~'J~/~'tn~ &, ~nO-~ Tax Acct. Lot Block Irreg. Lot Map rig Comer Phone No. BTS '"'~-.-~ t ~ Cross S~et <o~t~ ~ Use of Structure No. Employees BedroomsEXisting No. ~ BedroomsPr°P°s~l No. Water Supply: Private Well ( ) Spring ( ) Community Well ( ) City ( ) P'°PertyOwneO~qL~ I ~'~I~'Di }~'~.~ Mailing : .a~,~l~n~,wz~ Pho.eNo. ~.--Z. II{,, Auth. Agenl/Leasee Mailing Address Phone No. Contractor Business Name & Number Mailing Address Phone No. 3. FEES ** Fees include DEQ Surcharge ($30.00) $ Site Evaluation, Single Family Dwelling, first lot ......................................................................................................... $320.00 Site Evaluation, Single Family Dwelling, ea addl lot ...................................................................................................... 235.00 Site Evaluation, Commercial, first 1000 gallons ............................................................................................................. 320.00 Site Evaluation, Commercial 1000 - 5000 gallons .................................................................................... 320.00 + $90/500/gal + $100/500 gallons Site Evaluation, Rural Area Variance .............................................................................................................................. 320.00 Construction Permit or Commercial Major Repair, first 1000 gallons: Standard System ................................................................................................................................. 382.00 ,,...,..... , IP)lk' a J :: ", '.' "',' ,' ,:' ,' II1%)~ I iv. .... ,' '.",': ...... " 111% ' ' Gray Water: Disposal Sum'p ........ ~ .................................................... ~,~ ........ l..tr M..q....~r...1411~0.00'=~'- Pressure Distribution System ............................................................................ ,~S~gi...O....!.....k:.';5Y3.00 Redundant System ............................................................................................................................. 382.00 Sand Filter System ........................................................................................... Seepage Pit ....................................................................................................... I'~It-MSILII.~ .......... Duo---...~2.00 Seepage Trench ............................................................. Steep Slope ................................... ' ........................................ .~.IIIIiDIN~'"m~ ' Rs .......................................................................................... .' ........ 2.00 Tile Dewatering System ..................................................................................................................... 550.00 Construction Permit or Commercial Major Repair, over 1000 gallons: Construction Permit Fee + $25/500 gallons Commercial Plan Review 600 gallons - 1000 gallons ............................................................................................................... 133.00 1000 gallons - 2500 gallons ............................................................................................................... 133.00 + $25/500 gallons Commercial Minor Repair ............................................................................................................................................... 173.00 Single Family Dwelling, Minor Repair (tank only) ......................................................................................................... 130.00 Single Family Dwelling, Major Repair (drainfield) ........................................................................................................ 210.00 Residential or Commercial: Alterations .......................................................................................................................................... 378.00 Permit Renewal, Field Visit ............................................................................................................... 227.00 Permit Renewal, No Field Visit ......................................................................................................... 115.00 Authorization, Field Visit .................................................................................................................. 247.00 Authorization, No Field Visit ............................................................................................................ 117.00 - Existing System Evaluation ............................................................................................................... 247.00 Annual Evaluation/Alternative System .............................................................................................. 247.00 Annual Evaluation Temporary/Hardship Mobile Home .................................................................... 183.00 Annual Evaluation, Large System ..................................................................................................... 123.00 Pump or Dosing Siphon ....................................................................................................................... 25.00 Pumper Track Inspection, First Vehicle ............................................................................................................................ 67.00 Pumper Track Inspection, Ea Additional Vehicle ............................................................................................................. 40.00 Septic Reinspection Fee ..................................................................................................................................................... 25.00 Sepac Inspection for which no fee is specifically indicated .............................................................................................. 40.00/hr0~ ¢ [ g?om'~l.. Receipt: NameofApplicant(Pleas~e~'~'n~t':~{"~_-A_lk3t' ./~.-~.'[.~ S& Test Holes Ready: Signature of Applican,: ,~%.~f.~_ t~ .~{~a~_E~..~ Date: /"'~ "q~, Tank Pumped: MC 15-SI Rev 8/95 Pumping Certification Attached: (Y) (N)