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FOR OFFICEUSE ONLY
<br />Received By:
<br />ZomngValidation
<br />Date:
<br />
<br />MARION COUNTY BUILDING INSPECTION
<br /> 220 High St~t NE
<br /> Satel~ OR. 97301
<br />
<br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION
<br />1. Location of Installation
<br />
<br /> ~lllng 3/daSt~ ss: Phone No.
<br />AUth. Agen~.J~a~ ........ Malting Address: ' I Phone No.
<br />Contta~:lor B~i,~ss Nan'm & Number Mailin8 Address: Ph'~ne No.
<br />DEQ Licensed Contractor & No. l~iling Addwss: Phone No,
<br />
<br />3. Fees
<br />
<br /> Commer~{al CDSF -Dailv Sewage Flow} I
<br /> Site Evaluationt first 1000 ~a}. DSF 245,00 20.00
<br /> Sit~ Evaluation~ ea. ~d.I. 500 ~1, DSF 75.00 20,~/m
<br />
<br /> Slanda~ Syst~ less than 1000 ~l'. D~, 245.~ ' 10.00
<br /> $~nda~ $~m mo~ th~ 1000 g~. DSF:
<br /> $245.00 + $1 ~ e~,~, Mdl. $00 gal DSF i0.~0
<br /> e~ping Fill I 415,00 10.00
<br /> Holdin8 Tapk 245~00 10.00
<br /> ~epag~ ~eneh .... ~,~,S.00 10.00 ,, ,
<br /> I
<br /> Al~,~6~ns , , 245.00 10.00
<br /> g~ait+ Minor 75.~ 10.~
<br />
<br />.... go,nslm~tion Pemlt Rqn~wal ~o Fi~ld Vi~i~} 8~,~ , 10.00
<br /> ~is0 ag Sys~m Evaluaioa,,Repon ,, lf0.~ !0,00
<br /> Authod~tioa Noti~ {Fi*[d Visit) ..... 150,00 10,0~
<br />
<br /> Ann~al Evaluation of A[~matlve Sy~m 1 $0,~ 10~0
<br />
<br />~Tek if Applicable to Sbis Application}
<br /> Si Holes ar~ Dui[
<br /> ) I will ~all when Test Holes Dug
<br />
<br />) 1 am perfoeming work on a prop¢~y I own or occupy
<br />) I am a r~giste~d builder o}( ) lhe auihoti:~ed rcpr*~nOliw
<br />) Th~ work will b~ performed by a DEQ Lichn~d In.taller
<br />) Other
<br />
<br />Reside~ti'al Single Family" $
<br />Site Bvaluation~, first lot 24~.® 20.01)
<br />S~nda~ S~cm ,~45.~ 10.00
<br />Disooul T~nch in gaomli~ 245.00 l Q,.~0
<br />Gray W~r Di~o~ Sump 120.00 10.00
<br />mU[dS I~k ,,g~,S,O0 ~0.00
<br />Redundant 245.00 1,0,.00
<br />~nd Fil~r 445.00 ,, 10.00
<br />~ Slope ,,, 245,00 10.00
<br />Tile ~ng ,, , ~50,00 10,00
<br />Al~tlon 245.00 10.00
<br />Repairt ~or {d~in~eld) ~- ~ 115.00 10,00
<br />,~gpair, ~nor {~nk) ...., 75.00 10.00
<br />~nstmctlo~,,,p,~it Renewal (Fiqlg visit) 1 ~0-00 10.00
<br />~n~tmctlo~ pe~it ~newal (~g Field VisR} 85,.00 10.00
<br />,~inspe*gon Fe~ , 25.00 ~00
<br />Autho~ion ~oti~e (Fiel~ Visit) 150.00 10.~
<br />~uthod~io~ Notice (Ho Field Visit} 85.00 .I0.00
<br />Anau~ ~alu~o~Al~ative Sy~m 150.00
<br />Annual Ev~u~io~mp. or H~ahip ~ ~.~ ,00 /
<br />~ml Ama V~ance $i~ ~uation 245.00 20.~
<br />
<br /> Total S '
<br /> Receipt No,
<br />
<br />NAME OF APPLICANT (please print):
<br />
<br />SIGNATURE OF APPLICANT: DA'I/El
<br /> /
<br />
<br />MC 15-SI REV 2/93
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