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MARION COUNTY BUILDING INSPECTION
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<br />yes omc ys_. foN Y
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<br />Zoning V~idati~
<br />Date: __ ..~'
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<br />220 High So*et NE
<br />Salem, 0K97301
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<br />$:00 a, tn, - 4:30 pm Phone 588-5147
<br />Code-A-Phone 588-7904
<br /> FAX 588-794,~
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<br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
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<br />1. Location of installation
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<br />_2. Contractor InformaO. o~ ......
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<br />Property Owner I Maillng AddresS: Phone No.
<br />~uth. Age~LL~Se~ ..... Mailing AddresS: '" Phone No.
<br />contractor Bu;i.¢ss Name ........ & Number r]/~" ~[<'~ f ~X6, Mailing Address: . , Phone No.,, J d~ ~ ~$--
<br />Dg~ L,iee~se6 Contractor & N~, Mailing Add~e~: Phon~ ~o.
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<br /> ¢~ m m ¢zeja,L .(0..$_~92¢)
<br /> Site Evaluation, ea. ~ci.,I. 500 ~1. DSF ' 75]00 ~'6.001m
<br /> Standa~tem less than 1000 gal. DSF .... 245.00 lO,d0 '~.b
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<br /> $245.00 ,7~,',, $15 each addl, 500 gal DS~ 10.00
<br /> Cappin$ Fill 415.00 10,00
<br /> Disposal Trenches in ~pm~lit~ 245.00 10.00
<br /> Gray Water Waste D~qaal Sump ...... '
<br /> }toldin~ Tank .... 245.00 10,00 ....
<br /> Seepage Trench,,, 245,00 10,00
<br /> Tile,~atednR System ~,50.00 10,00
<br /> (For e~h addifiona1500 gal DSF , ,25~00 .00,
<br /> Alterations ~45,00 10.00
<br /> Re air Minor 75.00 10,00
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<br />Conslmcti~ Pennit Renewal ~o FieJ~,~slt~) 85,00 10,00
<br />Existing System E~a~[u~,tipn Repeal 150,00 lQ.,00
<br />..~,?l~ofizafion Notice (Fteld,,~isit) 150.00 10-00
<br />A utile fi~.~]j~n Notice (No Field Visit) ,,, 85.00 10.00
<br />~_Annual Evaluation of Alte~ative System 150.00 10,00.,
<br />Anaoal Evalqation of i,a~* Sgste~, 90~Q0 10,00
<br />Pumper T~,9,k Inspection, Fimt track 50;q0 .00
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<br />(Mark if Appllaal)le to this Application)
<br />(~ Test }Io1¢~ are Dug
<br /> ) I will call when Test Holes Dug
<br />
<br />I am per~bnlli0g work on a property I own or o~¢upy
<br />I am a registered builder ok ( ) the authorized representative
<br />The work will be performed by a DEQ Licensed Installer
<br />Other
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<br />_Residential Si'n'gl~, FamUy .....
<br />Site Igvaluatiot~r.l, irst lot ! 245.00 20.00
<br />Site Evaluatiog~ pa. adfll, lot 205.00 20.00
<br />Constmetio~ permit
<br /> 245.60 10,00
<br />__Capping ~ill 415,00 lO.0O
<br />Disposal TrenFh in Sapmiile 245,00 10,00
<br />,,, (gray water Disposal ,Sump ,, , 120,00
<br />_,,.H..oolding Tank ..... ~45,00 10.00
<br />P~.ssur~ Di~tdbution ,,350.00 10,00
<br />Redundan.t,, 245.00 10.00
<br />~and Filter 445.00 10,00
<br />.__~_ epag~ Tnmch 24,5.00 10.,00
<br />Jt~p Slope: 2-45.00 10,0O.,
<br />Tile Dewat~finl~ 350.00 10.00
<br />Allerat[oll 245,.00 10-00
<br />~..l~e.~e. pair, IVh, ior (d rain fi eld) 115.00 lQ.00
<br />Constmctlo~ Permit Renewal (Plaid Visit) ) 50.00 10.00
<br />~C.,Or$S C0c ion Permlt,,Renewal (No F~e d,,Vis* ) 85,00 I 0.00
<br /> Reinspection ,Fee.. ,,,25,00 .00
<br />Authori~,xtion Notice (Fie!d Visit) 150,00 10.00
<br />A ulhofizat ten Not ce (No Field, Vi~ ) ,,85,00 10.00,
<br />Existing System Evaluation 150,00 10,00
<br />Annual EYaluation/Altemative."System 1503)0 .00
<br />._.A..nnual EvaluatioIffTemp, or Hardship MH 90.00 .00
<br />Rural Area Variance Site Evaluation 245~00 20,00
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<br /> Receipt No.
<br />I agree to install according to the submitted plans and spcci:fic, ations, the laws
<br />of the State of Oregon and the ordinances of Marion County.
<br />
<br />NAME OF A~L~ (please print):
<br />SIG~~~: BATE:
<br />
<br />MC 15-SI REV 2/93
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