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MARION COUNTY BUILDING iNSPECTION
<br />
<br />'FOR OFFICE'"~JSE ONLY
<br />l~eceived By: __
<br />Zoning ValidaJion:
<br />Date: . , ,
<br />
<br /> 220 High Street NE
<br /> Salem, OR 97301
<br />
<br />g:00 am ~ 4:30 pm Plione 555-5147
<br />Code-A-Phon~ 588-7904
<br /> FAX 588-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br />Property Owner ] Mailing Addr~ Phone No. .
<br />
<br /> ~ ~ [ Sit~ ~? Use of S~cmre: ....
<br />S~R~vjsion ........ L~ I Bl~k No. Employees;
<br /> ........ ~z&; fig"
<br />Series ...... To~ip ReuSe ...... ~ao ..... Map
<br />
<br />Contractor Information
<br />
<br />Property Owner Mailing Address: Phone No.
<br />Auth, AgenffLeasee M~iling Address: Phone No,
<br />Contr~to~"l~lsiness Name & Number ....... ].,"" Mailing Addres's:" ", .--- Phone N;]
<br />DEQ Licensed ContraCtor & No, Mailing Address: Phone No.
<br />
<br />Residential Si~'g[~ Family .......
<br />Site ~valuafion~ Erst lot .......... $ 2(10.00 $20.00 $ .....
<br />
<br />C. ommerelal (DSF-Daily Sewage Flow)
<br />Site Evahlation, first~l~0~O gal, DS}~ ' $ ~'00.00 ;20,00 $ .....
<br />Site Evltimthon, eat, addl. 500 gal, I)SF -- 60.00 20.00/rr
<br />Coasm~¢tion & Repair Permits
<br />Standard ~r~iem less than 1000 ~;al. DSF 200,00 10,00
<br />Smndar~ ~,~.stem mere than 1000 gal, DSF:
<br />$200,00 + $15&ach addl. 500 gal, DSF 10.00
<br />'Cappihg Fill 330,00
<br />Dispesal Trend~es in Sapmlitt~ 200,00 I0.00
<br />Gray Wat*r Wmt* Disposal Sump 95.00 10.00
<br />Iloldiag Tank 200.00 I0,00
<br />Pressure Dislribution 280.00 I0,00
<br />?ePS!ge. eTreo eh 200,00 I0.00
<br />Plan Review
<br />
<br />· Fo.~t eayl_~_a~dditiorual 500 g.xl. DSF 20.00
<br />
<br />Constmelion Pemlit Renewal (Field Vislkq) 120.00
<br />Authorlzalion Ncale. e~e (No Field VBJt) 70.00 10,00
<br />Pumper 'l.~m.~e k?.._np~eetioa, ea. addl, truck 35.00
<br />
<br /> Sit~ ~vpluation, ea. addl. lot ..... 165,00 20,00
<br /> Construction permit
<br /> Standard System ...... 200.00 10'.t'~ ~-
<br /> Capping Fill ....... 330.00
<br />
<br /> Disposal T~cnch in Saprolite 200,00 10,00
<br /> Gray Water Dispos~,!,~ump 95.00 10.00
<br /> llolthng Tank 200.00 10.00
<br /> Pressure Distfibulion 286.00 10,00
<br /> Redundant ....... 200,00 1'0,0~
<br />
<br /> Seepage Trench 200.00 10.00
<br />
<br />..... .Til~ Dewate. dng 280,00 10,00
<br />Alteration 2'00,'00"
<br /> Repair, MaJ.?.(drainlield) 95.00 10,00
<br /> Repair, Minor (tank) 60,00
<br /> C0q{! .mellon Permlt Renewal (Field Visit) 120.00 10'[~ .....
<br /> Construction Permit Renewal (N,q Fie!d X(iAt) 70.00 10.00
<br /> Relnspect!q~ Fe?. ....... 25,00 .IX)
<br />
<br /> Authorization Notice (Fig?JViailQ -- 120.00 10.00
<br /> Authorization Ntalce (No field visit) 70.00 10,00
<br />
<br /> l~xlsfing System Evaluation ------ ~ ~
<br /> Annual Evaluation/Alternative System 120100 "' "'""'Jb~
<br /> Annual Evaluation/Temp, or Haxdsbip MH ___ 75,..~
<br /> Rural Area Variance Site Evaluation 200.00 20.00
<br />
<br />(Ma~k i/Applicable to tiffs Application)
<br /> Test Holes are Dug
<br /> I will call when Tes~ 14ole~ Dug
<br />
<br />) I am performing work on a property I own or occupy
<br />) [ am a reg}steted builder c¢ ( ) the authorized representative
<br /> of a registered builden
<br />) The work will be performed by a DEQ Licensed Im~t slier
<br />) Other
<br />) [ agree to install according to rite submitted plans and
<br /> speaificalions, th~ laws of the Stale of Or~,gon and the
<br /> ordinance,~ of Marion County.
<br />
<br />MC 15-74 REV 1/92
<br />
<br />Total
<br />
<br />Receipl No,____
<br />
<br />NAME OF APPLICAN 1' (please print)
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />
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