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L* ' ~/I ,~/~ ~a, ~ M . COMMUNITY DEVELOPMENT CENTER · IR¢¢¢ived By: J' {L.a"Dt,O ll,~{/-e~ ~.J 285 ~ch St. ~ - R~m 132 [ . ~ ~ ~ I ~ I S~,~gon97301 IZonmg Vah~ti?: ~ ~ I I 8:~a~:30pm Phone ~5147 I~-. 'OJ_~J- I Uhr. lns~nLine588-79~ OCT 2 Irote' ~-~ ~ [ SITE EV~UATION AND/OR SEPTIC PE~T APPLICATIO~RI0~ 1. LOCATION OF ~ST~LATION BHILDIR~ Subdivision Lot Blo~k No. Employees Section Townslfip Range Zone Map Water Supply: Pdvat~ Well ( ) Spring ( ) Lot Width Lot Depth Acres Irreg. Lot Comer Community WeB ( ) City ( ) 2. CONTRACTOR INFORMATION 3. Si~ Evalmtio~ Single Fmily Dwelling tint lot ......................................................................................................... $320.00 Site Evalmtio~ SM~e Fmily Dwalling ea ~dl lot ...................................................................................................... 235.00 Sim Evalmtio~ ~mm~ial, f~ I 0~ ~lons ............................................................................................................. 320.00 Site Evalmti~ ~mm~ 1000 - 50~ ~llons .................................................................................... 320.~ + $90/500/gal Site Evalmfi~ R~al ~ V~e .............................................................................................................................. 320.00 Cons~cfion P~it or Co~ Major R~ak, first 1000 gallons: Sm~ Syst~ ................................................................................................................................. 382.00 A~bic Sygm .................................................................................................................................. 218.00 C~Mg Fill Sys~m ........................................................................................................................... 593.00 Ces~ol ............................................................................................................................................. 382.00 Disp~al Tgn~ in Sapmlite .............................................................................................................. 382.00 Gray Wa~r Disposal Stop ............................................................................................ ~ .................. 190.00 Pressm D~bufion Syst~ ............................................................................................................. 553.00 Smd Filter Sys~m ............................................................................................................................. 703.00 Se~ge Pit ......................................................................................................................................... 312.00 Se~ge Tgnch .................................................................................................................................. 382.00 S~p Slope ......................................................................................................................................... 382.00 Tile D~at~g S~m ..................................................................................................................... 550.00 Cons~cfion P~it or Co~l Major R~air, ov~ 1000 gallo~: Co~ial Plm Review 600 g~lons - 10~ ~lons ............................................................................................................... 133.~ Co~i~ Minor R~ak ............................................................................................................................................... 173.~ ~ Sidle F~y DwallMg, Minor Repak (~ only) ......................................................................................................... 130.~ Sidle F~ly Dwal~g, Major R~ (~infiald) ........................................................................................................ 210.00 Resi~fiM ~ C~dal: Mm~om .......................................................................................................................................... 378.00 Pe~it Ren~, Field Visit ............................................................................................................... 227.00 Pe~it Rental, No Field Visit ......................................................................................................... 115.00 Au~ofizafio~ Field Visit .................................................................................................................. 247.00 A~ho~afio~ No Field VisR ........................................................................................................... 117.00 Existing System Emlmfion ............................ /. ................................................................................. 247.00 ~uM Ev~uafion Tempor~ship Mobile Home .................................................................... 183.00 ~u~ Ev~m~o~ L~ga Systm .....................................................................................................123.00 ~p or Dosing Siphon ....................................................................................................................... 25.00 ~ Track Inspection, Fimt Vehicle ............................................................................................................................ 67.00 S~fic Re~specfion F~ ..................................................................................................................................................... 25.00 S~fic Impecfion for which no fee is specifically indim~ .............................................................................................. 40.00~ MC 15-8I RevS~5 d// Phon~ No. + $100/500 gallons + $25/500 gallons gallons ~TestHolesl~eady: I0~ --9 ~ Pumping Certification Attached: (y) (N)