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FO CIiV USE ONLY <br />Received By: Dale: <br />Zoning By: City: <br />Receipt#: Amount:$ <br /> <br /> MARION COUNTy l~Jl[l,D LNG INSPECTION <br /> COMMUNIYY' DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br />8:00 am - 4:30 pm 24 bx. Inspection Line 373-4427 <br /> <br />FAX 588-7948 <br /> <br />ON-SITE SEWAGE DISPOSAL APPLICATION <br /> <br />1. JOB DgSCRIPIlON <br /> <br /> ( ) Site Evaluation ( ) New Installation ( ) Alteration l~Repair ( ) Authorization ( ) Existing System Report (for loan purposes) ( ) Other <br /> <br />Use of Stctlcture: No. Employees: Seating Capacity: Total # Existing Bedrooms: Total # Proposed Bedrooms: <br />2. LOCATION OF INSTALLATION <br /> <br />3. APPLICANT IN~ORMATION <br /> <br /> ( ) I am the PROPERTY OWNER an6 own, reside in, or will reside in the completed structure and will be my own general contractor. <br /> <br />FI am ~e AUTHORIZED REPRESENTATIVE O~ THE PROPERTY~)WNER: <br /> <br /> CiW: <br /> <br />Zip: Phone: <br /> <br />( ) I am 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 <br />Site Evaluation, Residemial, first lot $ 335.00 <br />Site Evaluation. Residential, ea addnl lot $ 205.00 <br />Sit~ Evaluation, Commercial, first 1000 gal $ 335.00 <br />Site Evaluation, Commercial, 1000-5000 gal $ 335.00 <br /> + $90/500 gal or part thereof above 1000 gal <br /> <br />Site Evaluation, Rural Ar~a Variance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for the first 1000 gallons <br />projected DSF; <br />Standard On-Site System $ 400.00 <br /> <br />A~mafiv¢ S ys~:m: <br /> Aerobic $ 400.00 <br /> 'Capffmg Fill $ 600.00 <br /> Cesspool $ 4~0.00 <br /> Disposal Trench in Saprolite $ 400.00,~ <br /> Evapotranspiratio n-Absorptio n $ 400.00 <br /> Cnay Wate~ Sump $ 200.00 <br /> Pressure Distribution $ 600.00 <br /> Redundant $ 400,00 <br /> Sand Fi~ $ 750.00 <br /> Seepage Pit $ 400.00 <br /> Seepage Trench $ 400.00 <br /> Steep Slope $ 400.00 <br /> Tile Dewatehng $ 600.00 <br /> Pump or Dosing Siphon $ 25.00 <br /> <br />For more than 1000 gallon~: $ 400.00 <br />+ $40/500 gal or part thereof above 1000 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required $ 250.00 <br />No Field Visit Required $ 90.00 <br /> <br />ALTERATION PERMIT <br /> <br />$ 400.00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />REPAIR PERMIT <br />,8ingle Family Dwelling, Major Repak <br />~ (Tank~Tlralnfield or Drainfield 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 />Commeroial Minor Repair $150.00 <br /> <br />ANNUAL EVALUATION <br /> Of an ALTERNATIVE SYSTEM $ 235.00 <br /> <br />B. COMM]gRCIAL 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 />thereofabeve 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 />F2(ISTING SYSTEM EVAL $ 250.00 <br /> <br />RECORDS REVIEW $ 40.00 <br /> <br />5. FEE TOTALS: <br /> <br />Al, Enter ToVd Fees from Se~ion 4A $ <br />A2. Add DEQ Surcharge($30.00.~ $ <br /> for each gem marked in /% <br /> Section "A' $ <br /> b'~l~o~l: $ <br />B. Enter Total from Section 4B $ <br />C. Reinspeetion Fee, $50.0/hour $ <br />D. Hourly I~specrion Rate, $50.O0/hour $ <br /> Total Amount Due: $ <br /> <br />Signature of App Date: <br />Test Holes Ready: ~ :7~0 ? ~(date) <br />Certification attached? Y / N [elr~l~ one] MC1~I <br /> <br /> <br />