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L JOB DESCRII~ION ( ) Site Evaluation ( ) New Installation ~ Lancaster Dr. NE - Suite C Salem, Oregon 97305 24 hr. Illspection Line 373-4427 FAX 588-7948 Use of S~ucmre: , No. Employees: To~l # Existing Bedrooms: ~_~ Total # Proposed Bedrooms: f 2. LOCATION O~ST~LATION Seeting Capacity: , 3. APPLICANT INFORMATION ( ) I am tho PROPERTY OWNER and own, reside ir~ or will reside in the completed structure and will be my own general contractor. ( ) I am the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: Bualaess Name (please print): Mailing Address: Street City: Zip: Phone: am a BEQ LICENSED INSTALLEP. x: Business Name (please print): ling Ad, s: FEES (Cirele the Appropriate Fee) A. SITE EVALUATIONS Site Evaluation, R~sidenti~ f~st lot $ 335.00 Site Evaluation, Residential, oa addnl lot $ 205.00 Site Evaluation, Commercial firet 1000 gal $ 335.00 Site Evaluation, Commercial, 1000-5000 gal $ 335.00 + $90/500galorpart thereof above 1000gal Site Evaluetior~ Rural Area VarLance $ 335.00 CONSTRUCTION PERMITS, for the fh'~t 100~ gallons projected DSF; Standard On-Site System $ 400.00 Altemetive System: Aerobic $ 400.00 Capping Fill $ 600.00 Cesspool $ 400:00 Disposal Trench in Saprolite $ 400.00 Evapotranspir~tion- Absoqnion $ 400.00 Oray Water Sump $ 200.00 Pressure Distribution $ 600.00 Redundant $ 400.00 Sand Flier $ 750.00 Seepage Pit $ 400.00 Seepage Trench $ 400,00 Steep Slope $ 400.00 Tile Dewateting $ 600.00 Pump or Dosing Siphon $ 25.00 ity: , Jffor' ip; q7 y3oq Phone: AUTHORIZATION NOTICE Field Visit Required $ 250.00 No Field Visit Required $ 90.00 ALTERATION PERMIT $ 400.00 PERMIT RENEWAL Field Visit Required $ 200.00 No Field Visit Required $ 85.00 REPAIR PERMIT Single F~mily Dwelling, Major Repair (Tank/Drainfield or Drainfield only) Single Family Dwe ing, Minor Repair (Tank only) $100.00 Commercial, Major Repair; Sec CONSTRUCTION PERMITS for fee Commercial Minor Repair $150.00 ANNUAL EVALUATION Of an ALTERNATIVE SYSTEM $ 235.00 For more than 1000 gallons: $ 40~.00 7~tgnature of Applicant:~ Test Holes Ready: t-~n° Certification attached~ y ! N Ictrde one] B, COMMERCIAL PL~-N REVIEW (cost of Plan Review is included in p~anit for systems up to 600 gallons) 600 gallons- 1000 galinns $135.00 1000 galbn~ - 2500 gallons $135.00 thereof abov 0 Fimt vt~c~each in~peetion $ 80.~tl~.~r each inspectio~~} 0 6 ~$ 45.00 5. FEE TOTALS: Al. Enter Total Fees from Section 4A A2. Add DEQ Surcharge(S30.00) for each item marked in Section "A" B. Enter Total from Section 4B C. R¢inspeetion Fee, $50.0/hour D. Hourly I~spe~tion Rate, $50.00/hour Total Amount Due: I '~(date) TankPuml~l?l)ate: