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I~OR CITY USE ONLY <br />Received By:_ Date: <br />Zoning By:_ City: <br />Receipt #: Amount:$ <br /> <br /> ~o~ cov~rrv mrmoma ~S~rCTtO~ <br /> COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lanc~er Dr. NE - Suite C <br /> Salem, O~gon 97305 <br />8:00 am - 4!30 pm 24 hr. Inspection Line 373-4427 FAX 588~7948 <br /> <br />ON-SITE SEWAGE DISPOSAL APPLICATION <br /> <br />1. JOB DESCRIPTION <br />I () Sit~ Evaluati°t~ ()NEW Installati°n O Alterati°n ~Repair () Auth°fizati°~() Exi'gS~m~n(f°r I°~P~°~s) ()~IUse of Stru~tur¢,'~/~ <br /> <br />No~ Empl0yees~/p~ Seating Capacity: <br /> <br />To~l # Existing Bedrooms: <br /> <br />Total # Proposed l~drooms: ~ <br /> <br />LOCATION OF INSTAIJ.~TION <br /> <br />Subdivision: Lot: Block: <br />Prop~ty LoeatoU Water Supply: (~Private Well ( ) Community Well ( ) City <br /> <br />3. APPLICANT INFORMATION <br /> <br />( ) I ara ~he AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: <br /> Buaine~$ Name (please prim):__ <br /> <br />Mailing <br /> <br />Street City: Zip: Phone: <br /> <br />( ) 1 m~ a DEQ LICENSED INSTALLER: <br /> Business Name (please print): <br /> <br />Mailing Address: <br /> <br /> Street City Zip: Phone: <br />4. FEES (Circle the Appropriate Fee) <br /> <br />A. SITE EVALUATIONS AUTHORIZATION NOTICE B. COMMERCIAL pLAN REVIEW (cost of <br />Si~ Evaluation, R~idential, ft~ lot $ 335.00 FieldVisit P~qair~d $250.00 PlauRcvi©w isin~ludedinpermR fo~syst~rr~up <br />Site Eye'on, Resid~fi~, ea addM lot $ 205.00 No Field Visit Req~d $ 90.~ ~ ~0 g~ons) <br />Si~ ~o~ Co~ci~, flint 1000 gfl $ 335.00 600 g~lons - 1000 gallom $135.00 <br />S~ E~Mu~on, Comcmi~ 1~5~0 gal S 335.~ ~TE~TION PE~ $ ~.~ 1~ 811on~ - 25~ g~lons $135.00 <br />+ $~/500g~orpm ~e~ofabov* l~0gM ~emofabove 1000g~ <br /> PE~T ~NEWAL <br />8~ E~u~on, R~ ~ea V~ce $ 335.00 Field Visfl Roq~ed $2~.~ PURER TRUCK ~SP~ION <br /> F~ Vehicle, e~h ~pe~on $ 80.00 <br />~NSTRU~ION P~T~ for ~e f~t 1~0 g~lo~ No Field VisR Requ~ $ 85.00 Each ~i~ Ve~cle, <br />C~apool $~0.00 ~ ~PA1RPER~T ~ <br /> <br />Phone:- ~7~ 20 ~'~ ' r Cerffiglcal~on aRached? Y / N [circle one] MCI~-81R~ 9t~ <br /> <br /> <br />