Laserfiche WebLink
FOR <br /> CITY <br /> USE <br /> ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> Received By: Date: ~ <br /> ReceiptZ°ning #:By: City: .. ! e,t~, u~-... Salem. Oregon 97305 <br /> II!~, ]~]0N ~aOO~lllg-00 em- 4:30 pm 24 hr. Inspection Line 373-4427 <br />............................... InsP ,niiN <br /> <br />1. ,lOB DESCRIPTION <br /> <br />FAX 588-7948 <br /> <br /> ON-S~E SEWAGE DISPOSAL APPLICATION <br /> / <br />( ) Site Evaluation ( ) New lnstellation ( ) Alteration ( ) Repair ~Authorizafion ( ) Existing System R~port (for loan purposes) ( ) Oth~r <br /> <br />Use of Stmaate: No. Employees: Seating Capacity: Total # Existing Bedrooms: Total # Proposed Bedrooms: <br />2. LOCATION OF ENSTALLATION <br /> <br />Map; ~n~: P~celSizo: ~,~ () 8F ~ nc UOB:()Y () N <br />~ ~e~or: W~ Supply: ( ) ~vm Well ( ) Co~ Well ( ) C~ <br /> <br />( ) I am the PROPERTY OWNER and own, reside m, or will reside in the completed s~ruclure and will Se my own general cona'actor. <br /> <br />( ) 1 am the AUTHORIZED REPRESEbFYATIVE OF THE PROPER~Y OWNER: Business Name (please print): <br /> <br /> Mailing Address: <br /> Street City: Zip: Phone: <br /> <br />( ) I am a DEQ LICENSED INSTALLER: <br /> Business Name ~lease print): License #: <br /> <br /> Mailing Address: <br /> <br />Str~et City: Zip: Phone: <br /> <br />4. FEES ( ,L~rcle the Appropria~ Fee) <br />A. SITE EVALUATIONS <br />Site Evaluation, Residential, firstlot $ 335.00 <br />Site Evaluation, Residential, ea addnl tot $ 205.00 <br />Site Evaluation, Commercial, fwst 10~0 gal $ 335.00 <br /> Site Evaluation, Conuner~iaL 1000-5000 gal $ 335.00 <br /> + $90/500 gal or part thereof above 1000 gal <br /> <br />Sit~ Evahmtica~ Rural Area Variance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for the first 1000 gallons <br />projected DSF; <br />S~mderd On-Site Sys~zm $ 400.00 <br /> <br />Alternative System: <br /> Aerobic $ 400.00 <br /> Capping Fill $ 600.00 <br /> Cesspool $ 400.00 <br /> Disposal Trench in Sapmlite $ 400.00 <br /> Evapotranspiration-Abs orptinn $ 400.00 <br /> Gray Water Sump $ 200.00 <br /> Pressure Distlibufion $ 600.00 <br /> Redundant $ 400.00 <br /> Sand Filter $ 750.00 <br /> Seepage Pit $ 400.00 <br /> Seepage Trench $ 400.00 <br /> Steep Slope $ 400.00 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required $ 250.00 <br />No Fiald Visit Required $ 90.00 <br /> <br />ALTERATION PERMIT <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />R~PA1R PERMIT <br />Single Family Dwelling Major Repair <br />(Tank/Drainfiald or Drainfiald only) $ 200.00 <br /> <br />Single Family Dwelling, Minor Repair <br />(Tank only) $ 100.00 <br /> <br />Commercial, Major Repair: See CONSTRUCTION <br />pERMITS for fee <br />Commercial Minor Repair $150.00 <br /> <br />B. COMMERCIAL PLAN P~V1EW (cost of <br />Plan Review is includ~cl in permit for system~ up <br />to 600 gallons) <br />600 gallons - 1000 gallops $135.00 <br />1000 gallons - 2500 gallops $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 />RECORDS REVIEW $ 4O.OO <br /> <br />& FEE TOTALS: <br />Al. Enter To~l Fe~ from Section 4A $ ~:~x.~O · <br />A2. Add DEQ Surcharge(S30.00) $~7~ ~ <br />for each item marked in <br />Section "A" $ <br /> Subto~: $ <br />B. Enter Total from Section 4B $ <br />C. Reinspeotion Fee, $50.0thour $ <br /> <br /> Tile Dcwatering $600.00 I D. Hourly Inspection Rate, $50 00faour <br /> Pump or Dosing Siphon $ 25.00 ANNUAL EVALUATION ~'-"~'~ t <br /> Ofaa ALTERNATUV'E SYSTEM $235.00 <br /> Formore than 1000 gallons: $400.00 <br /> $40/500 gal or part thereof above 1000 <br /> <br />M~lllaooAddresa: ¥"71 3 ~.,)l,g'~_ ,a~-O..A~-r /-..dO '/~,~ ~ Test Roles Ready: v (date) <br /> .~'r~X - ~? _m -- ,/..;J~ / C,rtmcaao..ttached?V/Nlarcleoaq <br /> <br /> <br />