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I F(~R C~ITY USE ONLY MARION COUNTY BUILDING INSPECTIO~I.c-.a~'I~IJ'~~'~ ' [Re?iv~ B~: __ 285 ~mh St. ~- R~m 132 ~ k~' ~ ~ !} ] S~ EV~UA~ON A~/OR SE~IC PE~ ~PLI~~ -.~-=g~0N Su~i~ ~.. ; ~.',,' : ' Lot Width Lot Depth 2, CONTRACTOR INFORMATION No.H~nployees ,,9.,.1~r' ~,,n..t- f &O fF'~ Water Supply: Private Well ( ) Six'ns ( ) Community Well ( ) City ( ) + $25/500 gallons + $251500 gallons Name of Applicant (Please Print): Signature of Applicant: MC 15-SI Rev 1/95 Receipt:, Test Holes Ready: Tank Pumped: Pumping Certification Attached: O0 (lq) ** 1~ include DEQ Surcharge Site Evaluation, Single Family Dwelling, first lot ..................................................... i ............ .~ ...... ~ .............................. $325.00 Site Evaluation, Single Family Dwelling, ea addl lot ...................................................................................................... 240.00 Site Evaluation, Commemial, first 1000 gallons .......................................................................................................... 325.00 Si~ Evaluation, C0~ 1000 - 5000 gallons ...... , ................... '...~ ....................................... i ........... ~ ....... [....325.00 Site Evaluation., Rund Area Variance ........................ :. ........................................................................ i ........................... 325.00 Construction Permit or Commercial Major Repair, first 1000 gallons: Standard System ................................................................................................................................. 387.00 Aerobic System .................................................................................................................................. 223.00 ~ -:.i. = . . Capping Fill System .................................................................................................................... 598.00 Cesspool ................~ ............... ~ .................................................................................... ~ ................. ;.....387.00 :. ~ ~ ~ : · Disposal Trench in Saprolite..2 ............................................................... · ......................... ~ ................. 387.00 Evapommspiration-Absorption System ....................................................................................... 223.00 ' ' Gray Water Disposal Sump ....: .......................................................................................................... 195.00 ~ i./. Holding Tnnk (Commercial only) ................................................................................................ ,....387.00 Pressure Distribution System ............................................................................................................. 555.00 R~lundant System ............................................................................................................................. 387.00 Sand F'flter System ............................................................................ ; ................................................ 708.00 Seepage Pit ............................................................................................... ~ ................. . ....................... 317;00 SeePage Trench .................................................................................................................................. 387.00 St~l~ Slopo ......................................................................................................................................... 387.00 Tile Dewatm-ing System ...................................................................................... : ....................... 555.00 Construction Permit or Commercial Major Repair, over 1000 gallons: Consffuction Permit Fee Commercial Plan Review 600 gallons - 1000 gallons ............................................................................................................... 133.00 1000 gallons - 5000 gallons ................................................ , .............................................................. 133.00 Commercial Minor Repair ................................................................................................................................ ~ .............. 178.00 Single Family Dwelling, Minor Repair (tank only) ............................................................................... ; ......................... 135.00 Single Family Dwelling, Major Repair (dr a infield) .................................................................................................... .....215.00 Residential or Commercial: Alterations .................................................................................................................................. 383.00 Permit Renewal, Field Visit ............................................................................................................... 232.00 Permit Renewal, No Field Visit ......................................................................................................... 120.00 Authorization, Field Visit .................................................................................................................. 252.00 Authorization, No Field Visit ................................................................................................... 122.00 Existing System Evaluation ............................................................................................................ 252 00 "Annual Evaluation/Alternative SyStem ............................ ; .................... : i.. i. . '.252100 Annual Evaluation Temporary/Hardship Mobile Home .................................................................... 188.00 An0ual Evaluation, Large System ............................................................................... 128 00 · '~ ' ~, ' ' 'Pump or Dosing Siphon ................ ~ ....................................... : ............................................................... 25.00 Pumpet~ Track Inspection, First Veh/cle ........................................................................................... 102 00 Pumper Track Inspection, Fa Additional Vehicle .................................................................. Septic Reinspection Fee ..................................................................................................................................................... 25.00 Septic Inspection for which no fee is specifically indicated .............................................................................................. 40.00/hr .:. '!~ + smo/soo g~aons Property Owner Mailing Address Phone No. Auth. Agen~ Mailing Address Phone No. · Commc~ Business Name & Number Mailing Add~ess Phone No.