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'""' .... "'"~'""'~'~ ~'N' "' ' MARION COUNTY BUILDING
<br />r~ ~rr~u~ ~x] 220 High S~t NE
<br />Remiv~ By: ~/~. I S~em, OR 97301
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<br /> EVALUATION AND/OR SE IC APE
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<br />1, Location of Installation
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<br />2. Contractor Information
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<br /> ComttlereJal (DgP-Daily Sewage Flow)
<br /> Site Ev~4uation, first I0OO gal DSF. $ 200,00 ;20.00
<br /> Site Ewduafion. ca, addl. 500 gal, DSF 60.0~ 20.OO/rr
<br /> Standard System I~a~ ~han 10OO, gal. DSF 200,00 10,00
<br /> $~00,00 + $15/~ach addl. 500 gal, DSF 10.00
<br /> capv~ng F,t,!, i30.00 i0.00
<br /> Gray Water ?Va~te DJ$17os~{ Sump ...... 95,00 I0,00
<br /> It0{diag 'l'ank 200.00 10,00
<br /> 'SccpageTtgneh ~d~) ,,. 200-00 I0,00
<br /> ~a'vv/r~,~ ~ 2oo. co moo
<br /> o00 g~3. DS~', 1001 g,L DZF 80.00 .00
<br /> (e,xeept SAND FII.TERS)
<br /> For eac!l additional 509 gal DSF 20,00
<br /> Alt~[afions 200.00 10,00
<br /> Co.~.n~)racfiorl p¢!rmh Renewal (~p Field ¥ifits) ,~ 70,(K) 10,00
<br /> Existing S sI~rnEvaluatior~ Re .... 1~0.00 10.00
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<br />Ammal Evaluation of Large System I 7~-00 10.00
<br />~umper Truck Inspection, First truck 50,00
<br />~Purnp~t Truck In~ection, cai'"addl, trock 35.00 .00
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<br />(Mark ff Applicable to Qfis Appljeafion) ) 3'cst l[ole3 are Dug
<br /> ) I will e&ll when Test Bole.~ Dug
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<br />alii perfuming work on a property I own or c~cupy
<br />am a registered builder ct ( ) the authori~d repre~¢ntativ~
<br />,~a registered btfildcr.
<br /> 'Fhe work will be per£ornled by a DEQ Licensed Ia~taller
<br /> Odxer
<br /> agrc~ to itlstaR according to thc ~ubtdicte~ p/ann and
<br />spc~ificalionn, tim laws of the Stat~ of Oregon and the
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<br />R¢*idenfial Single Fam/ly
<br />$it¢l~valuafiOn~fir~tlot $ 200,00 20,00 $
<br />~ite Evaluation, ea. addl, lot 165.00 20,00
<br />Colls~mction t~rmlt
<br />Standutd 8y~tom -- 200.00 10700
<br />Capping Fill 3301'0~
<br />~Disposal Trench in Saprolitc ' 200,00: 1'~),00
<br />Gray Water Di~al Sump 95.1Z ' iO,O0
<br />Hold~ng Tank 200,00! 10.~)
<br />~'Prc~suge Distljbudon 2gO,~ lO.00
<br />Realandant 2015.1X 10.00
<br />Sand Filter 355,0( 10.00
<br />~$*6page Trench , 200.012 lOT(X)
<br />Steep $lo~~ 200. ~ "J O.O0
<br />Til~ DewntoriEg 280,0~ 10.00
<br />Rep~¢, Major (drailxfield) 95.0C 10.00
<br />~eEair, Miao('0ank) 60,~ 10.00
<br />Cons~raction Pst'mit Renewal (~ield Vifit) 120.00 10.00
<br />Construction Permit Renewal 051o Field Visit) 70,00 10.00
<br />Relmpection Fee 25.0( .00
<br />Authorization Notice {Field Vlsi0 120.0(' 10.00
<br />Amhofizafion Node~ (No fi~jfl visit) 70.0~ 10,00
<br />E~isting ,~ystem Evaluatlon 120.{×] 'TO.00 .....
<br />Annual EvaluatiordT~mp. or I-Iatdship MH 75.00
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<br />SIGNATURE OF~,~PPLICANT:
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<br />MC 15-74 REV 1/92
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