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' i~$~,~ ~r t~e J~)l~t/l]UNI1Y DEVELOP1MFIqT CENTER ~:~ ~. I M%/1~0 ~c~.~- s~ c ' r n Jl/Is~, ~egon 97305 ~t:$ ~l__ , ~,_~:~:3~ 24~.~onL~373~27 F~588-7~8 , .................... L JOB DE--ION ~-Cr/0~ ~ ~ ~ ~ew Im~l~io~ (~ Mte~o~ ( ) ~pak ( ~ Amo~on ( ) Exi~ng Sy~ Ropoa (fo~ I~ p~) ( ) ~er Use of S~e: No. Employe~ Z ~CATION OF ~ST~TION ~ City: ' Zip: Cross Street: ~,~ Mailing Addre~"~o~.~. .~_'~Ci :. _- Zip: - v~eas~o: ?~ff~9~sF ~) AC Water Supply: ( ) Private Well ( ) Community Well ~) City UGB:A~Y () N a~n the PROPERTY OWNER and own. reside i~ or will reside in the completed structure a~d will be my own general contractor. om the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OV(NER: Business Name (please print): Mailing Address: City: Zip: Phone: am a DEQ LICENSED INSTALLF.~: Business Name (please Print): ~ 0¢~ ~X ~[~ ~ License#: ~.~/~ Mailing Address: ~ ~ ~2~O ~ 4. FEES (C~le Ihe Appropriate Fee) A. SITE EVALUATIONS Site Evaluation, Residential, first lot $ 335.00 Site Evaluation, Residential, ea addnl lot $ 205.00 Site Evaluation, Commercial, fu~t 1000 gal $ 335.00 Site Evaluation, Commercial 1000-5000 gal $ 335.00 + $90/500galorpart thcreofabovel000gal Site Evaluation, Rural Area Variance $ 335.00 CONSTRUCTION PERMITS, for thc fa~t 1000 gallons projected DSF; Standard On-Site System $ 400.00 Alternative System: Aerobic $ 400.00 Capping Fill $ 600.00 Cesspool : $ 400.00 Disposal Trench in Saprolite $ 400.00 Evapotranspiration- Absorption $ 400.00 Gray Water Sump $ 200.00 Pr~ssur~ Distribution $ 600~00 Redundant $ 400.00 Sand Fill~r $ 750.00 For more than 1000 gallons: $ 400.00 + $40/500 gal or part thereof above 1000 AUTHORIZATION NOTICE Field Visit Required $ 250.00 No Field Visit Required $ 90.00 ALTERATION PERMIT PERMIT RENEWAL Field Visit Required $ 200.00 No Field Visit Required $ 85.00 original permE~e ff an application for ~ Single Family Dwelling, Minor Repair (Taft. only) $100.00 Commercial, Major Repair: See CONSTRUCTION pERMITS for f~ Commercial Minor Repair $150.00 ANNUAL EVALUATION Of an' ALTERNATIVE SYSTEM $ 235.00 Name of ApldlCan~ [Please Print}:~ MallingAddress: - "*- --- ~ B. COMMERCIAL PLAN REVIEW (cost of Plan Review is included in permit for systems up to 600 gallons) 600 gallons - 1000 gal~ons $135,00 1000 gallons - 2500 gallons $135,00 thereof above 1000 gal PUMPER TRUCK INSPECTION First Vehicle, each inspection $ g0.00 Each Additional Vehicle, each in.apection $ 45,00 EXISTING SYSTEM EVAL $ 250.00 RECORDS REVIEW $ 40.00 5. FEE TOTALS: Al. Enter Total Fees from Section 4A $ re. Add DEQ SureSt(S30.00) $~. for each item marked in Section "A" $ " C. Rcmspection Fee, $50.0/hour $ D. Hourly Inspection Ra~e, $50.00/hour $ Total Amount Due: $ Siglmture of Appllcal~..~ ~1~:~ T~ ~o~ R~,~y: ~,, ~ ~ (,C~) T~n~:~' Cerflfleaflon aO~,~hed? y / N [eh'cb ~e] MC~S-S~ Ue~ 9~