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~ FOR CITY USE ONLY .. I~;ecei~eaBy: ~.~Q -IZ6ning Valclation: MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St, NE - Room 132 Salem, Oregon 97301 8:00am-4:30pm Phone 588-5147 24 hr. Inspection Line 588-7904 FAX S88~7948 ..... MARION COUNTY SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATIur~ BUILDING INSPECTION 1. LOCATION OF INSTALLATION .... PrlvateWell ( ) Sp~ ( ) ~t Wide ~ LOt Dep~ /~O Acm~ Ir~g. ~t Comer Community W~ll ( ) City ~ Site Evaluation, Single Family Dwelling, first lot ............................ i ............................................................................ $325,00 Site Evaluation, Single Family Dwelling. ea addl lot ....................... 2 .............................................................................. 240.00 Site Evaluation, Commemial, first 1000 gallons ............................. 5 ................................................. ~ ............................ 325.00 Site Evaluation, Comm¢mlal 1000: 5000 gallons ........................... : ..................................................................... ....,.32S.00 + $I00/500 gallons Site tgvaluatlon, Rural Area Variance .............................................................................................................................. 305.00 Construction Permit or ~ommercial Major Repair, first 1000 gallofis: Standard System .................................................. 2 .............................................................................. 387.00 Capping Fill System ............. ~ .............................. : ...................................................................... ,....598,00 Cesspool .................................... ,: ........................ ~ .............................................................................. 387.00 Di*posal Trench in Saprollte .................................................................................... : ......................... 387.00 £vapotransplration-Absoqnion Sysmm ............................................................................................. 22.3.00 G-ray Water Disposal Sump ................................ : .............................................................................. 195,00 Holding Tank (Commereinl only) ........................................ ............................ ,: ................................ 387.00 Pressure Dis~hution System .............................. ! .............................................................................. 555.00 Sand Filter System ............................................................................................................................. 708.00 Seepage Pit ............................................................... d....v.~ ................................ : ............................. 317.00 Seepage Trench ............................................ 2.....2 ................ : ....................................... : ................... :..387.00 Steep Slope ......................................................................................................................................... 387.00 Tile Dewatering System ...................................... : .............................................................................. 555.00 Construction Permit or Commercial Major Repair, over 1000 gallons: , Commerca P an Review 600 go.1 OhS - 1000 ga on~ ............................................................................................................... 133.00 1000 gallons - $000 gallons ............................................................................................................... 133,00 + $2fi/500 gallons Cotnmercial Minor Repair ............................................................................................................................................... 178.00 Single Felly Dwelling, Minor Repair (tank only) .......................... 2 ................... i .......................................................... 135.00 Single Family Dwelling, Major Repair (dralnEeld) ........................................................................................................ 215.00 Residential Co~------'-" , :383 00 Permit Renewal, No Field Viait .......................... i .............................................................................. lC0.00 Authorization, Field Visit ................................... 2 ............... i .............................................................. 252.00 Authorization, No Field Visit ............................................................................................................ 122,00 Existing System Evaluation ................................ : .............................................................................. 252,00 Annual Evaluation/Alternative System ............... 2 .............................................................................. 252.00 Annual Evaluation Tempora~y/l-Iatdship Mobile'HOme .................................................................... 188.00 Annual Evaluation, Large System ..................................................................................................... 128,00 Pump or Dosing Siphon ...................................... : ................ ; ............................................................... 25.00 Pumper Tmek InspeCtiOn, First Vehicle .......................................................................................................................... 102.00 Septic Inspectlon for which no f¢¢ is specifically indicated .............................. ................................................................ 40.00/hr .k~.Q ~'~q~L ~ NameofApplicant(Pl.,~q~Print),~/~,~{A,~/~ /~, '7~'~C~__~1~ "~~ Test Holes Ready: SignatumofApplicant: ~/ ~:~,~'~.~;~,-~g~.~ . __Date: Z--2~--P~ Tank Pumped: Pumpil}g Certification Attached: (Y)