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FOR OFFICE USE ONLY <br />~.eceiv~d <br /> Zoning Validation <br /> Date: <br /> <br />MARION COUNTY BUILDING I~SPECTION <br />220 High Street Nt~ <br /> Salem, OR. 97301 <br /> <br /> 8:00 a.ro. - 4:30 pm ?hone 588-$147 <br /> Code-A-Phone 555-7904 <br /> IrA~X 588-7948 <br /> <br />SiTE EVALUATION A~D/OR SEPTIC PERMIT APPLICATION <br /> <br />Location oflnstal] ~ti0n. <br /> <br />Contractor Information <br /> <br />ptope~y Owner ~ Mailing Add.ss: I Phott~'No, <br />~uth~ Ag~nULea~e I MailingAddIeS$: pboneNo, <br />~ont~etor Busineas Name & Nambcr Mailing Add.ss: I phone No. <br />D~ Licensed Co~t~c~r & No. ~ M~illng Add~as: Phon~ No- <br /> <br />Commercial (DSF - Daily Sc. wa~e Flowl $ <br />~te Evaluation, fi~t 1000 ~, DSF 245,00 20.~0 <br />Sits ~valuafio~, ea. addl, 500 gat. DSF 75.00 20.O0/m <br />Cappin6 Fill 415.00 10~0 <br />Disposal T~n~h~s i~ Sapm]ite 245.00 10,00 <br />~.d ~lt~ 445.00 I0-~ <br />Au hofizatioa ~oiiee (~, ~ d Visit) , 150.00 10.00 <br /> 6uthofization Notice ~o Field Visil) 85.00 10,0~ <br /> ~nnual Evaluation of A~tc~ative System 150,00 10,00 <br /> <br />(Mark if Applicable to this Application) ) Test Holes am Du8 <br /> ) I will eau when Test lloles Dug <br /> <br />) I am a ~gistered builder or ( ) the authorized ~p~,set~taiive <br />) Thc work will be performed by a DEQ Licensed Installer <br /> <br />R~siden,tial Simile Family is <br />Site l~valuatio~ first lot 245,00 20.00 <br />Site ]~valuation~ ea. addl. lot 20~,00 20.00 <br />Standard System ~45,00 10,00 <br />Capping Fill , 415,00 10,00 , -- <br />Dimpg~.l Trench in Sapt~il~ 245,00 1O,00 <br />G ,ra~, Water Di~osal Sump 120,00 I0,00 <br />Holding Tank 245.00 10,00 <br />preset* DistfibutJo~ 350,00 10.00 <br />P. edundant 245,00 10,00 <br />Sand Filter., 445,00 10.00 <br />Sacpa~e Trench 245,00 10.00 ,,__ <br /> <br />Aliemtloa 245,00 ,10.00 <br />P. epair, Majo~ (drainfield) ' 115.00 10,00 ~'~ <br />Authorization Notice (No Field Visit) 85.00 10.00 , <br /> <br />NAME OF APPLICANT (please print): <br />SIGNATURE OF APPLICANT: DATE: <br /> <br />MC ] 5-SI REV 2/93 <br /> <br /> <br />