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Received By:.-:'~---Y 220 High Street NE
<br />
<br /> Dale: ~/~/~'.,3 ....... 8:00 a.m.- 4=30 p~ Pho,e 588-5147
<br /> ~de-A-Phoae 588-7904 ~ 0~ ~,f~,~ ¥
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<br /> SI~ EV~UATION ~D/OR SEPTIC PE~IT ~PLICATION
<br />1. Location of Inst~llation
<br />
<br />Information
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<br />Auth. Agent/Lessee ~'~ J ' ' Mailing Addo~ss: t Phone No,
<br />ContractorBusin ss mc&Number · MallingAddmss:~ ~& ~,~ ~,; P~;~;'No~
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<br />Commercial (DSF -Dailv Sewa~,e Flow}
<br />She Evaluafion~ first 1000 ~al, DSF , , 245,00 ,20.00
<br />Site EvaluationI ca, addl, 500 8al, DSF 75,00 20.O0/m
<br />........ Cons motion & Repair F~rmi s
<br /> Standard System Ic~s than I000 ~al. DSF 245.00 10.00
<br /> Standard System mo~ than 1000 gaL DSF;
<br /> $245,00 * $15 each addl. 500 ~al. DSF i0100
<br /> ~pp!~g Fill 415,00 10,00
<br /> D~sposal Trenches in Saprolite 245.00 10,00
<br /> Gray Water WaSte I)i~lposa[~ump 120,00 !0-00
<br />~Tank 245.00 10-00
<br />Pressure Distribution 3S0,00 10,00
<br />Redundant System 245,00 10,00
<br />S~r~d Filter 445.00 lO-O0
<br /> Seepage 'rr~ncb 245.00 10.00
<br />Steep Slope ! 245.00 10,00
<br />Tile Dewatering System 350,00 10.00 ........
<br />Plan Review
<br />>'600 gal. DSF.< 1001 gal, DSF 100.00 ~00
<br />.... (.~1.~_~,I .B~XL.EII.~a~ ) ...........
<br /> (For ca~h additional 500 gal. DSF 25,00 .00
<br /> Alteratlo~ --, 245.00 10,00
<br /> Repair~ Minor 75.00 10.00
<br /> Constmstion Permit Renewal (Field Visits) 150.00 10,00
<br /> Consmlction Permit Renewal (No Field Visits) 85.00 10.00
<br /> 'Existing System Evaluation Report 150,00 10.00
<br /> A0thodzation Notice (Fi¢!d Visit) 150,00 10.00
<br /> kuthodzali,o,~,,~.o..t.i.c~.~No Field Visit~ ~ ~,00 10.00
<br /> Annual Evaluation of Alternative System 150,00 10,00
<br /> Annual Evaluati~u~f L~g~ System ~0,00 10,00
<br /> Pumper Truck Inspecfion, Fimt track S0.00 .00
<br /> Pumper Track.Ins eefion~ ca. addl. track
<br /> {q * nupe<:..A"'J-~ 35-00 .00
<br /> Other
<br />
<br />I am a registered builder or ( ) the authorized representative
<br />'lbe work will be performed by a DRQ Licensed Installer
<br />Other
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<br /> Residential Sinele Familv S
<br /> site Evaluationt first lot 245.00 20.00
<br /> $it~ Evaluation~ ea. addl. lot 205,00 20,00
<br /> Construction permit r
<br /> ~taodard System 245.00 10.00
<br /> Cappinlt Fill 415.00 10.00
<br /> DLsI>osaLTmn~h Jn Saorollte 245.00 10.00
<br /> ~ray ~?er Di~p0sa! Sump 120.00 I0.00
<br /> Holding Tank .............. 245.00 10.00
<br /> Pr~ssur~ Distribution 350.00 10.00
<br /> R~dundant 245,00 10.00
<br /> Sand Filter .... ~45,Q9 10.00
<br /> S*epase Tmnoh .............. 245.00 10,00
<br /> Steep Slope ............. 2~5.00 10.00
<br /> Tile Dewalerln$ 350.00 I 0.o0
<br /> · 5.],[~ratio~ ...... 245,00 I 10,00
<br /> ,Re.vair, Major(dminfield) 115.00I 10))0
<br />Repair. Minor (tank) 75.00 10.00
<br />Construction Permit Renewal ffigi~,,y}a'il5 150,00 I0.o0
<br />ll.COnsmetior~Peffil Renews 0q'oFedVst) 85,00 10.00
<br />Reinspection F~ 25.00 .00
<br />.,A,u,thorlzation Notice (Field Visit) 150,00 ..... !,9:99
<br /> Authorization. Nqgiee ,(No Field V s ) 85,00 10.00
<br /> Existing Sysla,m Evaluation 150.00 10.00
<br /> Annual Evaluation/Alternative System 150,00 ,00
<br /> Annual Evaluation~Temp, or H.ardshlp MN 90.00 .00
<br /> Rural Area variance Site Evaluation 245.00 20.00
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<br /> Receipt NO,
<br /> I ague to install according to thc submitted pla~s and specifications, the laws
<br />' ofth~ Slate of Ox~gon and thc ordlnanees of Marion County,
<br />
<br />NAME, (please print):
<br />
<br />SIGN~TU~OF AP,PLiCAI~': ~' DATE:
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<br />MC 15-SI REV 2/93
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