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FOR OFFICE IJSE)ONLY <br />Received By:~t~ ~ <br />ZonlngYaljd~'ion f'{~/ 1 <br />Date: [-I[ ~]~ <br /> <br />MARION COUNTY BUILDING INSPrFqCTION <br /> <br /> 285 Church St. NE - Room 132 <br /> Salem. Oregon 97301 <br /> <br /> $:00a.m.-4:30pmPhoneS88-5147 ~]~Nt 2 ' ' 1111 <br /> Cod*-A-Phone 588-7904 1~5 fm~ <br /> FAX 588.7948 <br /> <br />1. Location of Installation <br /> <br />Mobile Home Park ~, .... Spac~ <br />Section ff~ [ To~shlp qZ ~ ~age / ~ ] Zone ~ <br /> <br />2. Contractor Information <br /> <br />Auth, AgelWLea~ee Mailing Address: Phone No. <br />C~;iraetorBusinessName&Number. ff~) ,/',.-- '//~t~-j~CY'V',.9' .,Z-,Z ~iliagAdd~ss:/~ ~.~ PhoneNo. ' .............................. <br />DEQ Licensed Cont~tor & No. ~/ ~ili~g Add~s: Phone No. <br /> <br />__C,?m m~:cia! ~SF - Daily Sewm,~ e Flow) <br />S0e ~valuatlon, first 1000 fsi. DS~ 245.00 <br />StaBda~ 8~*~ Ieaa than 1000 <br />s~ndard System mo~ than 1000 gal. DgF: ........ <br />$245.00 + $15 ~a~h addl. 500 <br />Capping ~!l 4 <br />Holding, Ta~k .................. 245-00 <br />Pressure Distribution 3~0.00 <br />Redundant System 245.00 <br />~n~l F~ 445-00 <br />Seepa~e Tgneh <br /> <br />(Mark if Applicable to this Application) ) Tesl Holes arc Dug <br /> ) 1 will call when Test HoI~ Dug <br /> <br />1 am a registered builder or ( ) the authorized ~pteseatative <br />The work will be performed by a DEQ Licensed Installer <br />Other <br /> <br />MC 15-S1 REV 8/94 <br /> <br />Residential Single Familv <br />Site Evaluation~ first lot 245,00 <br />Site Evaluat ten~ ea. addL lot 205.00 <br />Construction permit <br />Standard System 245,00 <br />Capping Fill 415.00 <br />jl~i~p0~l Tr~neb in Saprolite 24fi.00 <br />Gray Water Disposal Sump 120.00 <br />Holding Tank 245,00 <br />Pressure Distribution 350,00 <br />Redundant 245.00 <br />Sand Filter 445,00 <br />S~epage T~n~h 245,00 <br />Steep Slope 245.00 <br />'Hie Dewatefin$ _ 350.00 <br />AOeratlon 245,00 <br />Re0air~ Major (d rain Ii'id) ______ 115-00 <br />Repair, Minor (tank) 75.00 <br />Constmetion Permit Renewal (Field Visit) 150.00 <br />Construction Permit Renewal (No Field Visit) 85.00 <br />Reinspeation Fee ____, 25,00 <br />Authorization Notice (Field Visit) 150,00 <br />Authorization Notlee (No Field Vigil) $5.00 <br />Existing System Evaluation ] 50.00 <br />Annual Evaluation/Alternative System 150.00 <br />Annual !avaluationff'emp. or Hardship MH ~0100 <br />Reml Area Variance Site Evaluation 245.00 <br /> <br /> [-1,o.1, <br /> Receipt No. <br />I agree to install according to the submitted plans and specifications, the laws <br />of the State of Or~gon and the ordinances of Marion County, <br /> <br />NAME ~OF APPLIcA~(pleflse print ): <br />~IGNATURI~ OF APP/,I,,i~.ANT. <br /> <br />DATE: <br /> <br /> <br />