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FOR OFFICE USE ONLY
<br />Received By:
<br />Zoning Validation
<br />Date:
<br />
<br />MARION COUNTY BUll,DING INSPECTION
<br />
<br />S:00 a.m.. 4:30 pm Phone 58S-5147
<br />Code-A-Phone 588-7904
<br /> FAX 5S8-7948
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br />Ptopqrty @wher ...... [ MailinsJ ,.~.~ress ....... ?hone
<br />lob Add,ss T~ Acct, No. ,,. C~ss Sncct ..........
<br /> Si~ No. Use of,$tmcto~ ...........
<br />Snbdivision ~t Block No.~Em Ioye~8 . ..........
<br />Mob e Hom~,,.~rk Spz~e ~ ~'
<br /> { I~. ~'i .Co~.r.,
<br />
<br />2. CoJ~tractor Information
<br />
<br />Propew/Owner Mailing Addtoss: Phone No,
<br />Auth, Agent/Lcasee Mailing Address: Phone No,
<br />Contractor Business Name & Numbe~ ..... Maili~ ~'~tmss: Phone No,
<br />DEQ Licensed ConOactor & No. i~iailing AddreSs: Fhone No.
<br />
<br />Fees
<br />
<br />'C~nmercial (DSF - Daily Sewage FI0v~ .......
<br />Site ??uationr li~t I000 ~1. DSF 245.00 ............ ~p.O0
<br />......Site Evaluatlon~ ga. ~dl, 500 Ssi, DSF , ................... 75.00 20.00/m
<br />Construction & ReE~,~,~its
<br />....Standard Sys~m loss than 1000 ~al, DSF 2~:~, 10.00
<br />?anda~ $~s~m more than 1000 gal. DSF: ........
<br />$245.00 + $15 each ~dl, 500 gal. D~.,,,,,,, ' 10`00
<br />Cappin~ ~ill 415`00 10,00
<br />Di,posal T~n~es i~ S~li~ 245,00 10.00
<br />Holdin~ T~nk .... 24~.00 10,00
<br />pgs~,~,,~i,tfibution 350.00 10`00
<br />Redundant System 245,00 10`00 .................
<br />~pa$~,,~nch 245,00 10,00
<br /> Steep Slope ......... g~,!.09 ........ ~0.o0
<br />T Ic,D~,~,g,!dng System ~50.00 10`00
<br />Plan Review
<br />::'600 ~al. DSF,< I001 gal, DSF 100.00 .00
<br />Alterations .............. 24~.00 10`00
<br />Repair~ Mino,r ..................... 7~,00 10;00
<br />Cpg~tion Pemlt Renewal (Field Vista) : 1~0.00 . 10,00
<br />Construction Pe~it Renewal ~o Field VisiB) 85`00 10,00 .....
<br />Aa/ho fizaio,a ,~9[~!~,,f ~iald Visk> lf0,00 I0-00
<br />Autho~tion Notic* ~o Field Vi~i0 SS,00' 10,00
<br />......~Onual Evaluation of Al~malvc System 150,00 10`00
<br />~mper Track I n spqqli,~,n~},,~ di, track 35,00 `00
<br />~hcr
<br />
<br />(Mark iFApplicabl¢ to this Application) ) Test Holes gte Dug
<br /> ) I will ~all when Test Holes DUB
<br />
<br />) I am performing work on a property I own or occupy
<br />) I am a registered builder or ( ) the authofiged representative
<br />) The work will be performed by a DEQ Licensed Installer
<br />) Other
<br />
<br /> Residential Sinl!le Family $
<br />Site Evaluation, first lot 245.00 20`00
<br />Site Evaluation, ~a. addl, lot 205-00 20.00
<br />Stend.~ System 245,00 ..... iO.O0
<br />Capoing Fill 415`00 10,00
<br />Disposal Trench in Sapmlite .................. ~45.00 10.00
<br />GrEy Water Disposal Sump 120.00 I0,00
<br />Holding Tank 245.00 10,00
<br />Pressure Distribution 350.00 10`00
<br />_Redundant 245.00 10,00
<br />Sand Filter 445.00 10`00
<br />S~epage Trench 245,00 10,00
<br />Steep ~?p~ 245.00 10`00
<br />Alteration 245,00 10`00
<br />Repair, Major (drainEeld) 115,00 10`00
<br />Repair, Minor{tank} 75.00 10,00
<br />Construction Permit Renewal (Field Vislt) 150,00 10,00
<br />Construction Permit Renewal (No Field Visit) 85,00 10,00
<br />
<br /> Authofizatlon Notic~ (Field yisit), , !~9.00, , ;lq,~q0 .........
<br /> Autho~i~ Notice (No Field Visit~ ~ 85,00 J0,00
<br /> Existing Sy*tem Evaluation I $0.00 10.00
<br /> Annual Evaluation/Alternative System IS0.00 ,00
<br /> Rural Aga Variance Sit~ Evaluation 245,00 20,00
<br />
<br />Total $
<br />Receipt No,
<br />I agge to install a~ording to the submitted plans and specifications, thc laws
<br />of the State of Oregon and the ordinances of Marion Couaty.
<br />
<br />NAME OF APPLICANT (Please print):
<br />SIGNATURE OF APPLICANT: DATE:
<br />
<br />MC 15-SI REV 2/93
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