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Receipl #: Amount:$ <br /> <br />1. JOB DESCRIPTION <br /> ( ) Site Evaluzlio. ( ) New Installalion ~ration <br /> <br />8:00 mn - 4:30pm <br /> <br />COMMUNITY DEVELOPMENT CENTER -- <br /> 3150 Lancaster DL NE - <br /> Salem, Or~gon 97305 <br /> 24 hr. Inspection Liao~ 373-4427 FAX 588-7948 <br /> <br />~Repair ( ) Authorization ( ) Existing System Report (for loan purposes) ( ) Other <br /> <br />Us~ of $,=ucture: /.,~() ffc~ NO. Empinyee~: S~ating Capacity: To~d # Existing B~drooms: Total # Proposed <br />2. LOCATION OF INSTALLATION <br /> <br />.division: w q , <br />Map: ivr ozOr Vf'zo e ' r ' F aSize: 7 ,37) SF O AC <br /> UGBi~/fY <br /> ()N <br /> <br />Prop~'yLocator: WaterSupply: ( ) Private Well ( ) Commu~yWell ,k)City <br /> <br />3. APPLICANT INFORMATION <br /> ~I am the pROPERTY OWNER ~nd own, reside in, or will reside in the completed structure and will be my own general contra~inr. <br /> ( ) I ara the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: Business Name (please print): <br /> <br /> Mailing Address: <br /> Street Cits: Zip: <br /> <br /> ( ) I am a DEQ LICENSEI) INSTALLER: Business Name (please print): <br /> <br />License #: <br /> <br />Mailing Address: <br /> <br />S~reet City; Zip: Phone: <br /> <br />4. FEES (Circle the Approprl~e Fee) <br /> <br />A. SITE EVALUATIONS <br />Si~ Evaluation, Residential, f~st lot $ 335.00 <br />Si~ Evaluation, Residoaf~[, ea addul lot $ 205.00 <br />Site Evaluation, Commercial, fa'st 1000 gal $ 335.00 <br />Site Evaluafion~ Commercial. 1000-5000 gal $ 335.00 <br /> + $90/500galorpart thereofabove 1000gal <br /> <br />Site Evaluation, Rural Area Variance $ 335.00 <br /> <br />CONSTRUCTION PER~TS, for the first 1000 gallons <br />projected DSF; <br />Standard On-Site SysWm $ 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 /> Ev apoltimap~vation-Absovptiors $ 400.00 <br /> Gray Water Sump $ 200.00 <br /> Pressure Distributio~ $ 600.00 <br /> Redundant $ 400.00 <br /> S~ad Filter $ 750.00 <br /> Seepage Pit $ 400.00 <br /> S~page 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 />+ $40/500 gal or part thereof above 1000 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required $ 250.00 <br />No F~etd VisR Required $ 90,00 <br /> <br />ALTERATION pERMIT <br /> <br />$ 4O0.00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />REPAIR PERMIT <br />Single Fanfily Dwe0ing, Major Repair <br /> (Tank/Dvaiufield or Dminfm Id only) <br /> <br />Single Family Dwellhlg, Minor Repair <br />(Tank only) ~ <br />Commercial, Major Repair: See CONSTRUCTION <br />PERMITS for fee <br />Commercial Minor Repair $150.00 <br /> <br />ANNUAL EVALUATION <br /> Of an ALTERNATIVE SYSTEM $ 235.00 <br /> <br />B. COMMERCIAL PLaN REVIEW (cost of <br />Plan Review is included in permil for systems up <br />to 60~ gatinm) <br />600 gallons - 1000 gallons $135.00 <br />1000 gallons - 2500 gallons $135.00 <br />thereof above 1000 gal <br /> <br />PUMI~ER TRUCK INSPECTION <br />First Vehicle, each inspection $ 80.00 <br />Each Addition~l Vehicle, <br />each inspection $ 45.00 <br /> <br />EXISTING SYSTEM EVAL $ 250.00 <br /> <br />RECORDS REVIEW $ 40.00 <br /> <br />5. FEE TOTALS: <br /> <br />Al. Enter Total Fees from Section 4A $ <br />A2: Add DEQ Surchzxg*($30.00) $. <br />for each item marked in <br /> <br />B. Enter T0tal from Section 40 $ <br />C. Reinapeetion Fee, $50.0/hour $ <br />D. Hourly Inspection Rate, $50.00/hour $ <br /> Total Amount Du~: <br /> <br />Malll~oAddress: ~ O. /~ ?X? ? H,~/( ~'--~ ?2},x~zstHolesReady: (date) TmtkiNmlped?Date:__ <br />Phone: ~Y,)"~, - ~0.$~'~--' -~q?erfifleaflon attadted? Y / N [circle one] MCI~81Rzv 9te~ <br /> <br /> <br />