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FOR CITY USE ONLY Received'By: _. Z~ning Validation: Date: 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 588-7948 SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION 1. LOCATION OF INSTALLATION Property Owner O ~¥'~ ~ ~A[ JLa"' [ ~'~J (~ h I M~ling Address ~ s. vision Lot Widthc:~ %0 Township0~- I Range ~:~ 2. CONTRACTOR INFORMATION Tax Acct. Lot Block t g.,.ot I Phone No. ~e-~7 -- 7_~~ useofs~uc~ 13om ¢ No. Employees Existing No. (~Bedrooms Bedrooms Proposed No. ~"~ Water Supply: Private Welt ~ Spring ( ) Community Well ( ) City ( ) Pr°pertyOwner.~._(~k.]'~ ~LLFi~ ~.~.]/"1 MailingAddress/~/~.~t))//Lty ~/~ ,PhoneNo. "~//~.--~ Conla'actor Business Name & Number - ~ ,.J - ~ -I Mailing Address Phone No. 3. FEES ** Fees include DEQ Surcharge ($30.00) Site Evaluation, Single Family Dwelling, first lot ......................................................................................................... $320.00 Site Evaluation, Single Family Dwelling, ea addl lot ...................................................................................................... 235.00 Site Evaluation, Commercial, first 1000 gallons ............................................................................................................. 320.00 Site Evaluation, Commercial 1000 - 5000 gallons .................................................................................... 320.00 + $90/500/gal Site Evaluation, Rural Area Variance .............................................................................................................................. 320.00 Construction Permit or Commercial Major Repair, first 1000 gallons: Standard System ................................................................................................................................. 382.00 Aerobic System .................................................................................................................................. 218.00 Capping Fill System ........................................................................................................................... 593.00 Cesspool ............................................................................................................................................. 382.00 Disposal Trench in Saprolite .............................................................................................................. 382.00 Evapotranspiration-Absorption System ............................................................................................. 218.00 Gray Water Disposal Sump ............................................................................................................... 190.00 Pressure Distribution System ............................................................................................................. 553.00 Redundant System ............................................................................................................................. 382.00 Sand Filter System ............................................................................................................................. 703.00 Seepage Pit ......................................................................................................................................... 312.00 Seepage Trench .................................................................................................................................. 382.00 Steep Slope .......................... : .............................................................................................................. 382.00 Tile Dewatering System ..................................................................................................................... 550.00 Consu'uction Permit or Commercial Major Repair, over 1000 gallons: Construction Permit Fee Commercial Plan Review 600 gallons - 1000 gallons ............................................................................................................... 133.00 1000 gallons - 2500 gallons ............................................................................................................... 133.00 Commercial Minor Repair ............................................................................................................................................... 173.00 Single Family Dwelling, Minor Repair (tank only) ......................................................................................................... 130.00 Single Family Dwelling, Major Repair (drain field) ........................................................................................................ 210.00 Residential or Commercial: Alterations .......................................................................................................................................... 378.00 Permit Renewal, Field Visit ............................................................................................................... 227.00 Permit Renewal, No Field Visit ......................................................................................................... 115.00 Authorization, Field Visit .................................................................................................................. 247.00 Authorization, No Field Visit ............................................................................................................ 117.00 Existing System Evaluation ............................................................................................................... 247.00 Annual Evaluation/Alternative System .............................................................................................. 247.00 Annual Evaluation Temporary/Hardship Mobile Home .................................................................... 183.00 Annual Evaluation, Large System ..................................................................................................... 123.00 Pump or Dosing Siphon ....................................................................................................................... 25.00 Pumper Truck Inspection, First Vehicle ............................................................................................................................ 67.00 Pumper Truck Inspection, Ea Additional Vehicle ............................................................................................................. 40.00 Septic Reinspection Fee ..................................................................................................................................................... 25.00 Septic Inspection for which no fee is specifically indicated .............................................................................................. 40.00/hr + $100/500 gallons + $25/500 gallons + $25/500 gallons Name of Applicant (Please Print): Signature of Applic~ff~?~ MC 15-SI Rev8/95 Receipt: Total: Test Holes Ready: Tank Pumped: Date Pumping Certification Attached: (Y) (N)