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L Lou,~fion of' Installation <br /> <br /> MA RiON CO. UNT¥. BijiLDiNG iNSPE(~N[[~ ~ <br /> Salem, OR 97:301 <br /> 8:0Oam-4;30pm Phone~88-5147 ~1~0~ COUNTY <br /> <br />St'rE EVALUATION ANn/OR SEIrrlG PP_RZlVI1T APPLICATION <br /> <br />Aere.~ In-eg. Lot <br /> <br />.?~aeme Busi~es~ Name & Numlx~ <br />~DEO licensed Contractor & No. <br /> <br />Cmilfflor¢ial (DSF-Daily $ow~,:~c Flow) ' <br />Ske Evalua6on~ 6~$t 1~ gnl, ~F <br />,~.[anc~ard S y.qtem Ics~ ~an 1~ gal, DS~ .............. 2~,~ 10,~ <br />,~)?d~d System m~o tl~n 1~ gal. <br />........ k?'~ + $~5/,~ ~am. 5~ ~l, 0st .......... "~o,~ <br /> Capplug Fill 33~ 10-~ <br /> Gray Wtger Waat~,,,~i$~al ~U~p 95.~ 10.~ <br /> Holding Tank <br /> Jh'e~surc Dis*ributlon 280~ 10.~ <br /> Sand ~jltcr ~S,~ 10.~ <br /> 6o0 g.L ;)st, ~] ~{. DSt ~0.~ <br /> Exis~Jng $yszem gv~.aOou R~n 120,~ 10,~ <br /> Autfiorlr~d<m N~ico (Field ~t) , I~2~ 10-~ <br /> Pumper Track {ns~c~on F r~k 50.~ <br /> <br />(Mark if Apll <br />( ) 'l~:~t ilo]~ are Dug <br /> <br /> of a registered btlilder, <br />( ) '1)1¢ work will be p~¢formed by a DEQ Licens~l h~stallet <br />( ) O01ec <br /> <br />Mailing A~Idrcss: <br /> <br />Phone No, <br />Phone No. <br /> <br />............... I P~,on¢ Nc,. <br /> <br />]~wider, tlal Sit~$]<, Pamily <br />Si~ gvaluafi~, f~st <br />mP~"gYa[ ............ 3~oi~ --~' ,, <br /> <br />915~al Trench ~ Saprolite 2~,~ 10.~ <br />~ Dl~don .... 280-~ 10~ ......... <br />Sand Fil~ ................... ~5~ --~ <br />S*~g* Tmne~ ........... 2~.~ 10.~) <br />Steep ~ 2~,~ 10,'~ <br />~lc ~wa~ng ................... ~0,~ 10.~ <br /> <br />gepai~, Minor {tan~) ~ ] '~'~['~ iO:~ ...... <br /> <br />Cons~ucfioa Pernfit R~neW~ {No Fi,l~ Visit) i"~ i0.~ ............ <br /> <br />R~ns~alon Fe* . 25..~ .~ "" ""ff.". <br /> <br />Au~fiou N~ ~o field vi~0 70.~ l 0.~ <br /> <br />& /4. <br /> <br />DATE: <br /> <br /> <br />