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~FOR OFFICE~U~E O~LY[ MARION COUNTYTBUILDING INSPECTION · Salem, OR 97301
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<br /> S~ EVALUATION ~D/OR SE~IC ~ APPLICATION BUILOIN~. iNSPECTION
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<br /> " ~ ....... ~ Si~ No. Use of S~e: ~ ........
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<br />Mobile Ho~ P~k S~e ~ ~
<br />S~o. ~" ~t~lTow~;Up ~ 'l~nge / ~ I~ne ~[ .Map w,~w~:
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<br />2. Contractor lnfornmtlon
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<br /> 26¢ -et/3?
<br />Au~. Agen/~ee ~ng ~ss: ~oae No,
<br />Con~a~or Business Na~ & Num~ M~ag Add~*: Phone No~
<br />DEQ ~censed Contr~t~ & No, M~liag Address: Phone No,
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<br />Commercia! (DSF-DaiI[ Sewal~e Fl,ow)
<br />Si ~ Bvaluafion~ first 1000 gal, DSF $ goo.00 320.00 $
<br />Site,Evaluatlon, ea. eddl. 500.$a. DSF 60.00
<br />Construction & Repair permit.~ , ,
<br />Sta~flar~, S.,ystem less than i060 g~l. DSF 2OO.OO 10.00
<br />Standard,,~ystem more than 10OO,sal. DSF:
<br />$200.00 + $15/each ,~ddl. 500 g{I, DSF 10.00
<br />Cappifig Fi!!,,, 330.00 iO,OO
<br />Di~l:~S~:l, Tr enche,~ in Saprolite, ........ 200,00 10,00
<br />Gray Water W~sto Disposol Sump ..... 95,OO 10.00
<br />l-lolding Tank 200.00 I0,OO
<br /> 2S000 to.oo
<br />Redued~nt S~stem ...... 200,00 t0.00
<br />Sand Filter ~5~.00
<br />Seepage, Tm.,nch 200JX 10.00
<br />Steep Stope ........... 200.0( 10.00
<br />Tile D~w~terln~ ,q~stem 2g0,0~ 10.00
<br />Plan Review
<br />600 gal, DSE lool ~a/."DsF 80.0~ ,00
<br />(except SAND FILTERS)
<br />For each adthfi~nal SOO gal. DSF 20.IX ,00
<br />A!terations , 2OO,(X 10.00
<br />Repalr~M]nor OO,0( 10.00
<br />Construction ,?*~mit Renewal (Field Visits) 120.IX 10.00
<br />Conslm¢fion,,pulrnit Renewal (No Field Visits) 70.0~ 10.OO
<br />.E_ xisting System l~valuation Report 13.0.0~ I0,oo
<br />Authorization Not;ir* ~ield Visit) 120.0~ 101OO
<br />Authori~adou Ne~tiee (N? Field Visit) ,79'~ 10,OO ' '
<br />Annua!,~,valuatioll of Alternative System 120,fX 10.00
<br />Annual Evaluation ..... o£ Larvae System. ,,,, 75,O2 10.00
<br />Pum~r Truck Inspection, First truck ,, 50.0~ .00
<br />Pumper Truck Inpseetio. n,!,.~a, atldl, track 35.0~ ,00
<br />Other
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<br />(Mark if Applicable to this Application) ) T~t Holes a~¢ Dug
<br /> ) I will call when Test Holes Dog
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<br />I am parforrrdng work on a p~r~y I own or occupy
<br />1 a~n a registered builde~ or ( ) the authorized representative
<br />of a registered bdlder,
<br />The work will be performed by a DEQ Licensed Installer
<br />Other
<br />I agree to in~tall according to the submitted plus and
<br />,qpeejficalions, the laws of the State of Oregon and the
<br />ordlnan¢~s o~r Marion County,
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<br />,,Site t~valuafion~ f~st lot $ 2~,OO $20.'~
<br />Cons~cfion ~r~t
<br />2~.~ 10,~
<br />Ca~ing Fill 330.~ 10.~J
<br />Di~s~ Trench in Saproht6 2~,~ 10.~
<br />Holing Tank 2~.~
<br />~ss~ ~bufion 280.~ 10.~
<br />Redunda~ 2~.~ 10,~
<br />S~ Filt~ 35~.~ 10,~
<br />S~ge Trench 2~,~ I0.~
<br />~ns~cfign P~t R*now~ ~o Field Vih
<br />'g~sfing System Evaluafiq,~ 120.~ 10~ .......
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<br />I Total $* 7_1 O, o~° '[
<br /> R ,ipl
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<br />LI~2qT~(p~eaSexprint):
<br />SIGNATURE OF~APPLI~2ANT: DATE:
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<br />MC 15-74 REV 1/92
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