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POll L'TI'Y USEiJ~iL]/9 , COMMUNITY DEXwd~OPMENT CENTI~ <br />Received By:~J~{~.eg~Dale: ~.%___jp-r.- ~ ~ 3150 Lancaster Dr. NE - Suite C <br />Receipt #: Amouaxt:$ [ : - 4:30 pm 24 kr. Inspection Line 373-4427 FAX 588-7948 <br /> <br />1. JOB D[SCRIPTION <br /> <br /> MARION COUNTY <br />BUILDING INSPECTIOI -srr£.sEwAcE DISPOSAL <br /> <br /> ( ) She Evalual/on <br /> <br /> Use of Strueture: <br />2. LOCAIION OF h'~tSTALLATION <br /> <br />( ) New Installation ( ) Alteration ( ) Repair ( ) Authorization ( ) Existing Syst*m Rapoa (for loan purposes) ( ) Other <br /> <br /> No. Employees: Seating Capacity: Total # Existing Bedrooms: O T°tai # Pr°P°sed Bedr°°ms:~'~ <br /> I <br /> <br />Site^d : 13o ~{~ city:D~I~0t~ Zip: ??30r crogsst et:7' bL '6 <br />~ ~cator: Water ~apply: ( ) ~vate Well ( ) Co~i~ Wall <br /> <br />3. APPLICANT INFORMATION <br /> <br /> ( ) I am the PROPERTY OWNER and own. ro~.i& in. or will reside in the completed shn~xtr e and will be my own getx~ral ~otara~tor. <br /> <br /> ( ) I am the AUTHORIZED REPRESENTATIVE OF THE PROPERTY 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 (please print): <br /> <br />License #: <br /> <br />Mailing Address: <br /> <br /> Street City: Zip: Phone: <br />4. FEES (Circle the Appropriate Fee) <br /> <br />Site Evaluation, Rural Area Variance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for the lest 1000 gallons <br /> <br />projected DSF; <br />Standard On-Site System $ 400.00 <br /> <br />Alternative System: <br /> Aerobic $ 400.00 <br /> Capping Fill $ 600.00 <br /> Cesspool $ 400.00 <br /> Disposal Trench in Saprolite $ 400.00 <br /> Evapolnmpiration-Abaorption $ 400.00 <br /> Gray Water Sump $ 200.00 <br /> Pressure Disffibntinn $ 600.00 <br /> Redundant $ 400.00 <br /> Sand Filter $ 750.00 <br /> Seepage Pit $ 400.00 <br /> Seepage Trench $ 400.00 <br /> Steep Slop* $ 400.00 <br /> Tile Dewatering $ 600.00 <br /> Pump or Dosing Siphon $ 25.00 <br /> <br /> For more than 1000 gallons: $ 400.00 <br /> <br />AUTHORIZATION NOTICE ~ [ <br />FISM Visit Required <br />No Field Visit Required <br />ALTERATION PERMIT $ 400.00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 20¢00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br /> NOTE: Renewal ora permit my be granted In <br />the original permittee ff an application for permit <br />renewal is ~ed prior to the original <br />expiration date. <br /> <br />REPAIR PERMIT <br />Single Family Dwelling, Major Repair <br /> (TanUDrainfield ot Drathfield only) <br /> <br />Single Family Dwelling, Minor Repair <br />(Tank only) $100.00 <br /> <br />Coramerciai; Major Repair: See CONSTRUCTION <br />PERMITS for fee <br />Commercial Minor Repair $150.00 <br /> <br />ANNUAl, EVALUATION <br /> <br />500 gal or part thereof above 1000 <br /> <br />B. COMMERCD. L PLAN REVIEW (cost of <br />Plan Reviex~ is in¢ludeA in permit f~r sys~r~ up <br />to 600 gallons) <br />600 gallons - 1000 gailons $135.00 <br />1000 gallons - 2500 gallons $135.00 <br />thereof above 1000 gal <br /> <br />PUMPER TRUCK INSPECTION <br />First Vehicle, e~h inspection $ 8030 <br />Each Additional Vehicle, <br />each inspecl/on $ 45.00 <br /> <br />EXISTING SYSTEM EVAL $ 250.00 <br /> <br />RECORDS REVIEW $ 40.00 <br /> <br />FEE TOTALS: <br /> <br />Al. Enter Total Fees from Section 4A $ <br />A2. Add DEQ Surcharge(g30.00) $~.~ <br />for each item ma~ked in <br />Sectinrt "A" $ <br /> Subtotal: $~?~ <br />B. Enter Total from Section 4B $ <br />C. Reinspection Fee, $50.0fnour $ <br /> <br />D. Hourly Inspection Rate, $50.00/hour Total Amount Due: <br /> <br />Of an ALTERNATIVE SYSTEM $ 235.00 <br /> Signature of A pplicant ~~ ~~ <br /> Test Holes Ready: _(date) Tank Pumped? Date: <br /> Certification attacht~? Y / N [circle one] MC1~81 <br /> <br /> <br />