Laserfiche WebLink
Received By Date: <br />Receipt #: Amount:$ <br /> <br /> ~PR - 7 , , 3150 Lancaster Dr. NE-SuiteC <br /> MARION COUNTY Salem, Oregon 97305 <br />BU!LDi~i~o ~N 24 hr. Inspection Line 3734427 <br /> <br />1. JOB DESCRIPTION <br /> <br /> FAX 588-7948 <br />ON-SITE SEWAGE DISPOSAL APPLICATION <br /> <br />( ) Site Evaluation <br /> <br />Use of Slmeture: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />( ) New Installation ( ) Al~ralion ( ) Rep~A~horizalion ( ) Ex~sting System R~port (for loan pml~oses) ( ) Oth*r <br /> <br /> No. ~nployees: Sealing capacity: Total # Existing Bedrooms: Total # Proposed Bedroon~: <br /> <br /> Site Address: <br /> <br /> Property Locator: <br />a~ <br /> <br /> City~' Zip: 3 Cross Street: <br /> Mailing Address:/~ss.'~ ~'- ~ZZ~Z$~, <br /> Lot: Block: <br />~ () AC <br />Water Supply: ( ) Private Well ( ) Communi~Well ~City <br /> <br />Pm~el #: <br /> <br />Phone:g93- Y75~ 5- <br /> <br />UOB:J~Y () N <br /> <br />( ) I am the PROPERTY OWNER a~td 0wn~ r~side iai o~ will reside in the completed structure and will be my own general ¢0mraetor. <br /> <br />mn the AUTHORIZED REPRESENTATIVE OF THE PROPERTy OWNER, / i _.j.~ <br />Busine~ Name (please print): <br /> <br /> Mailing Add.ss: <br /> <br />( ) I am a DEQ LICENSED INSTALLER: Business Name (please print): <br /> <br />Cily: Zip: <br /> <br />Mailing Address: : <br /> <br /> Street City: Zip: Phone: <br /> <br />4. FEEs (Circle the Appropriate F~) <br /> <br />A. SITE EVALUATIONS <br />Site Evaluation, Residential, first lot $ 335.00 <br />Site Evaluation, Residential, ea addnl lot $ 205.00 <br />Site Evalu*tion, Commercial, first 1000 gal $ 335:00 <br />Site Evaluation, Commercial, 1000-5000 gal $ 335.00 <br /> + $90/500galorpart thereofabove 1000gal <br /> <br />Site Evaluation, Rural Area Variance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for the first 1000 gallons <br />projected DSF; <br />Standard On, Site System $ 400.00 <br /> <br />Alternative Systmm: <br /> Aerobic $ 400.00 <br /> Capping Fill $ 600.00 <br /> Cesspool $ 400.00 <br /> Disposal Trench in Saproli~ $ 400.00 <br /> Evapotranspiralinn- Abso~ptinn $ 400.00 <br /> Gray Water Smnp $ 200.00 <br /> <br />For more than 1000 gallons: $ 400.00 <br />+ $40/500 gal or part thereof above 1000 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required <br />No Field Visit Required~'~0. <br /> <br />ALTERATION PERIVffF <br /> <br />$ 400,00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />expiration d~te. <br /> <br />REPAIR PERMIT <br />Single Family Dwelling, Major Repair <br /> (Tank/Drainfiald or Drainfield only) <br /> <br />$ 200.00 <br /> <br />Single Family Dwelling, Minor Repair <br />(Tank only) $100.00 <br /> <br />Conm~er¢ial, Maj or RePair: see CONSTRUCTION <br />PERMITS for fee <br />Commercial Minor Repair $150.00 <br /> <br />ANNUAL EVALUATION <br /> Of ma ALTER.NATIVE SYSTEM $ 235.00 <br /> <br />Signatare of App~--~t <br /> <br />Nmne of Applicant [Please Print]:~ <br /> rvlaffi~g Address: ~' ~ 'J - ~ ~ Test Holes Ready: <br /> Phone: <br /> <br />B, COMMERCIAL PLAN REVIEW (cost of <br />Plan Review is included in permit for systems up <br />to 600 gallons) <br />600 gallons - 1000 gallons $135.00 <br />1000 gallons - 2500 gallons $135.00 <br />thereof above 1000 gal <br /> <br />PUMPER TRUCK INSPECTION <br />First Vehicle; each inspection $ 80.00 <br />Each Additional Vehicle, <br />each inspection $ 45.00 <br /> <br />EXISTING SYSTEM EVAL $ 250:00 <br /> <br />RECORI~ REVIEW $ 40.00 <br /> <br />5. FEE TOTALS: <br /> <br /> Fees from Section 4A <br />Al. <br /> Enter <br /> Total <br />A2. Add DEQ Surcharge(S30.00) <br /> for each item marked in <br /> Section "A" <br /> Subtotal: <br />B. Enter To~al from Section 4B <br />C. Reinspectinn Fee, $50.0/hour <br />D. Hourly Inspection Rate, $50.00/hour <br /> Total Amount Due: <br /> <br />Certification atlached? y / N [circle one] ~t R~ ~ <br /> <br /> <br />