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FOR CITY USE ONLY R, eceived By: --,- Z~oning V, al~dation: Dat~: ' ' 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 [ Mailing Address Job Address ~ Tax Acct. No. Use of Structure Subdivision No. Employees Lot Width gl~ 0 Lot Depth / ~ 0 Acres Zone Irreg. Lot Map Comer PhoneNo. & ~/-5'~ Y/ Cross Strut 0'¢~ /e//~,/ ,~/ Existing No. Proposed No. Bedrooms Bedrooms Water Supply: Private Well ~ Spring ( ) Community Well ( ) City ( ) 2. CONTRACTOR INFORMATION Property Owner Mailing Address Phone No. Auth. AgenffLeasee 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 Site Evaluation, Rural Area Variance .............................................................................................................................. 320.00 Construction Permit or Commercial Major Repair, first 1000 gallons: Standard System ................................................................................................................................. 382.00 Aerobic System .................................................................................................................................. 218.00 Capping Fill System ........................................................................................................................... 593.00 Cesspool ............................................................................................................................................ 382.00 Disposal Trench in Saprolite ..................... : .............. ~ ............................................................... 382.00 Evapotranspiration-Absorption System ................ /~:. ....... 2 ......................................................... 218.00 Gray Water Disposal Sump .................................. ? .......................................................................... 190.00 Pressure Distribution System ........................................... ~. ............................................................... 553.00 Redundant System .................................................................. .~ ................................................... 382.00 Sand Filter System ......................................................................... ~.... ~...,~ .................................... 703.00 Seepage Pit ........................................................................................... ~ ....................................... 312.00 Seepage Trench .................................................................................................................................. 382.00 Steep Slope ......................................................................................................................................... 382.00 Tile Dewatering System ..................................................................................................................... 550.00 Construction Permit or Commercial Major Repair, over 1000 gallons: Construction Permit Fee Commercial Plan Review 600 gallons - 1000 gallons ............................................................................................................... 133.00 1000 gallons - 2500 gallons ............................................................................................................... 133.00 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 ..................................... 2 ................................................................................. 25.00 Pumper Truck Inspection, First Vehicle ........................................................................................ : ................................... 67.00 Pumper Truck Inspection, Ea Additional Vehicle ............................................................................................................. 40.00 Septic Reinspection Fee ..................................................................................................................................................... 25.00 Septic Inspection for which no fee is specifically indicated .............................................................................................. 40.00/hr + $100/500 gallons + $25/500 gallons + $25/500 gallons .'~ q7, oo Name of Applicant (Please Print): ~ ~ Signature of Applicant: MC IS-SI Rev 8/95 Date: Receipt: Total: Test Holes Ready: Date Tank Pumped: Pumping Certification Attached: (Y) (N)