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FO~, OFFICE USE ONLY
<br />~eeeived By:
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br />220 High Steer N]~
<br /> Salem, OR 97301
<br />
<br />$:00 &m,-4:30 pm Phone 588-5147
<br />Code-A-Phone 588-7904
<br />FAX$88-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br /> ........... ~ ,7,, S,i~,~o.
<br />.... Sgbdivlaiou .................. ~t Block
<br />Mobile I{om~ P~R .... Spa~e ,~ ..........
<br /> ~tio~ 24 ~o~hip 04 ~ 2W Zonet~,~t MaP
<br /> ~t Width ~t ~p~ A,ms 3 0 · 0 6 ......... ~mer
<br />
<br />Contractor information
<br />
<br />PmPe~Y°wne~obert & E. Williamson Mailin~Add~mAurora,0R Ph°neN~78-5588
<br />Auth. Agent/Lessee Mailing Add.ss; Phone No.
<br />Contractor Business N~ Number ~iliag Add.ss: Phone No,
<br />DEQ Licen~d Cont~etor & No. ~l{ag Addmsm Phone No,
<br />
<br /> Dim
<br />3. Fees F~ ~,~, ~.,,~
<br />
<br />Daily mow) i
<br />$it~ Evaluatlon~ first 1000 gal. DSF 245,00 20.00
<br />SRo EvaluatiOn, e~ addh ~00 gal DSF 75.00 20,00/m
<br />Construction & ~palr Pe~its
<br />Stand~ System less than 1000 ~1, DSF 245.00 10,00
<br />gt~nda~ System mo~ than 1000 gal. DSF:
<br />g245.~Q + $[~, ~,Sh,,~dl. 500 gal. DSF 10,00
<br />Capping Fill 415.00
<br />Disposal Trenches ia Sap~lite ~45.00 10.00
<br />Gray Wate~ Waa~ Disposal Sump 120.00 10.00
<br />Holdin~ Tank 245.00 I0.00
<br />Pressure Distribution 350.00 I0,00
<br />Redundant System 245,00
<br />~a~d Filter ~-00 1O-00
<br />~epage T~ench 245,00 10,00
<br />Sleep Slope 24f00 10,00
<br />~le De~ate~ng Sys~m 350-00 10.00
<br />Plan REviEw
<br />>600 gal, DSF,< 1001 gal DSF 100-00 ,00
<br />Construction Pemit RengWal (Field Visits) . 150.00 10,00
<br />F~istlag Sys~m ~valuatlon Repo~ 1 $0,00 10,00
<br />Authod~tion Notice (Field Visit) 150.00 10,00
<br />Authod~atlon Notice ~o Field Visit) 85.00 I0,00
<br />Annual Evaluation of Alternative Sys~m 1~0-00 10,00
<br />Annual Bvaluation of La~e Sy*tem 90-00 10,00
<br />Pumper Tmek Inspeetion~ Fi~t track 50,00 .00
<br />
<br />(Mark it'Applicable to this Application) ) Tes~ Holes ay: Dug
<br /> ) I will eat} when Test Holes Dug
<br />
<br />) I am a registered builder ~r ( ) the authorized representative
<br /> 'the work will be performed by a DEQ Licensed Installer
<br /> Other
<br />
<br />Residential Single Familv ' '
<br />Site Evaluafion~ first lot 245.00 20,00
<br />Sits Evaluation, es, addl, lot 205,00 20-00
<br />Construction permit
<br />
<br />Capping Fill , 415.00 10,00
<br />
<br />Gray Water Disposal Sump 120,00 10.00
<br />Floldiag Tank 245.00 10.00
<br />Pressure Distribution ~50,00 lO,O0
<br />Redundaut 245.00 10,00
<br />Sand Filter 445,00 10.00
<br />S~epage Tt~nch 245.00 10.00
<br />Steep Slope 245,00 10,00
<br />Tile l>ewatefin$ 350.00 10,00
<br />Alteration 245.00 10.00
<br />P~palrI Major (dmlnfield) 115.00 10.00
<br />Repair, ~nor (tank) 75.00 lO.OO
<br />Constmctlon Permit Renewal (Field V.!~!~) 150,00 10-00
<br />Rei~spe~tion Fee 25.00 .00
<br />Authorization;Notice (Eio!~,,,~,i,~i,t) , 150,00 10.00
<br />Authofi.~ttion Notice (No Field Visit) .............. 85-Q0 10.00
<br />Existing System Evahation 150,00 10.00
<br />Annual Evaluation/Alternative System 150.00 .00
<br />Annual Evaluation/reap, o* Ha.~.,.~.h, ip Iyll~ , 90-00 ,00
<br />Rural Area Variance Site Evaluation 245.00 20.00
<br />
<br /> Re¢o pt No
<br />I agree to install according to the submit~d plans and spe¢ificatious, the laws
<br />
<br />N~ME OF ~k~PPLICANT (please print):
<br />
<br />MC 1S-SI REV 2/93
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