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Da).~ R CITY USE ONLY <br />eived By: _ _ _ <br />ning Validation: _ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> 8:00am~l:30pm Phone 5~8-5147 <br /> 24 hr. Inspection Line 373-4427 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />1. LOCATION OF INSTALLATION <br /> <br />lq RS'I <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />~o~No. 9,3_~7B -Il'/Z_ <br />Cross Street ~ <br />UsO of Sl~ugmr~ f_~~.~ <br />No. Employes J <br /> <br />Water Supply: <br />Pdvale Well (~Spfing ( ) <br />Community Well ( ) Cit~ ( ) <br /> <br />PropenyOwa~r [MailingAdd~ess,~r.,~. ~ '104~.~0~]Ph°neN°' ~e*t,e- ~ O~ <br /> <br />3. FEES <br /> <br />Sit~ Evaluation, Commercial 1000 - $000 gallons .................................................................................... 320,00 + $90t500/gal <br /> <br /> 600 gallons - 1000 gallons ............................................................................................................... 133.00 <br /> 1000 gallons - 2.500 gallons ............................................................................................................... 133.00 <br /> <br />+ $100/500 gallons <br /> <br />+ $251500 gallons <br />+ $25/500 gallons <br /> <br />Name of Applicant (Pl~as~~ <br />Signature of Applicant:t~~~ _ <br /> MC 15 SI Rev 8/96~. <br /> <br /> Total: <br />Test Holes RFady: ~ <br />Tank Pumped: ~ <br /> <br />Pumping Certification Attached: <br /> <br /> <br />