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Received By:o,x~4~]~) Date: ~ ,[ <br /> <br />Receipt #:_ Amoum:$ I <br /> <br />JOB DESCRIPTION <br /> <br />AU6 1 7 19 <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />3~5o Lan~er ~r. ~- s.it~ c MARION COUNTY" <br />s.t~, O~o. 9730s o~mua~uSPECTIn" <br />8:00 am, 4:30 pm 24 ~. ~tion L~c 373~27 - <br /> <br />( ) Site Evaluation ( ) New Installation ( ) Alteration XRepair ( ) Authorization ( ) Existing System R~por~ (for Ioan'pu~oaes) ( )/Olher <br />Us~ofStructUre: /~a N0. EmployeOS:~- geatingCapacity: ~ T°tal#Exstingl~&oom~! I~ Total#Propes~lB~&o0ms: ~ <br /> <br />2. LOCATION OF INSTP, I,I ATION <br /> <br />3. APPLICANT INFORMATI <br /> <br />( ) 1 am the PROPERTY OWNER and own, reside h~ or will reside in the completed structure and will be my own general contractor. <br /> <br />( ) I a~ the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: <br /> Business Name (please prmt): <br /> <br />Mailing Address: <br /> <br />City: Zip: Phone: <br /> <br />4, FEES (Circle the Appropriate Fee) <br /> <br />: A, SITE EVALUATIONS AUTHORIZATION NOTICE B. COMMERCIAL PLAN REVIEW (cost of <br />Site Evaluation, Residential, first lot $ 335.00 Field Visit Required $ 250.00 Plan Review is included in permit for systems up <br />Site Evaluation~ Residential, ea addnl lot $ 205.00 No Field Visit Required $ 90.00 t~ 600 g~lons) <br />Site Evaluation, Commercial, first 1000 gal $ 335.00 600 gallons - 1000 gallons $135.00 <br />Site Evaluation, Commercial, 1000-5000 gal $ 335.00 ALTERATION PERMIT $ 40~.00 1000 gallons - 2500 gallons $135.00 <br />+ $90/500galorpart thereofabove I000gal thereofabove 1000gal <br /> PERMIT RENEWAL <br />Site Evaluation, Rural Area Vafia~ace $ 335.00 Field Visit Required $ 200.00 PUMPER TRUCK INSPECTION <br /> First Vehicle, each inspection $ 80.00 <br />CONSTRUCTION pEILMITS, for the fa-st 1000 gallons No Field ¥isit Required $ 85.0~ Each Additional Yehicle, <br />projected DSF; each inspection $ 45.00 <br />Standard On-Site System $ 400,00 NOTE: Renewal cfa permit nmy be grsnted to <br /> the orl~inal permlttee ff an applic~ton for permit EXISTING SYSTEM EVAL $ 250.00 <br />Pressure Dis~xibution $ 600.00 Single Family Dwelling, Minor Repair A2. Add DEQ Surcharge(S30.00) <br />+ ~o~ 5oo gal o~p~th~of ,~ove 1000 / ~, <br /> <br />Mat.-eAadre~: gQ~tO ~O P~_~r [~ P~o~.t&~n z'a~q'~o~' TestHoL~sReady:/'~_ / (date) Tm~kPumpe~?D~t~: <br />Phone: ~) 'g -Ia '~" - '2...q 0 ~' __ Certtaealion attael~ Y I N Idrek oriel <br /> <br /> <br />