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FOg CIT..Y USE ONLY Redei~,ed B~: Zoning Validation: ~Date: 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 1. LOCATION OF INSTALLATION Subdivision Block EVALUATION AND/OR SEPTIC PERMIT APPLICATION Pho.e o. Cross Street Section Township Range Zone Map Lot Width Lot Depth Acres Irreg. Lot Comer Use of Structure No. Employees Existing No. ~ Proposed No. '~ B~lrooms f~n,.. Bedrooms '"~..~ Water Supply: Private Well ( ) Spring ( ) Community Well ( ) City (~/~ 2. CONTRACTOR INFORMATION Property Owner Mailing Address Phone No. Auth. Agent/Leasee Mailing Address Phone No. Contractor Business Namc & Number ~ ~/~O_.~t~,~d ~)~ J,/~.,L,) ~3 Mailing Address 7,,v c t, ftrv4 O_eNo. ~$5' ~0 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 Construction 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 (drainfield) ........................................................................................................ 210.00 Residential or Commercial: Alterations .......................................................................................................................................... 378.00 Permit Renewal, Field Visit ............................................................................................................... 227.00 Permit Renewal, No Field Visit ........................................................................................................ .1 l_J. fl~ Authorization, Field Visit ................................................................................................................ ~'~7 aa-"~ Authorization, No Field Visit ............................................................................................................ 1 I7.00 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 °fApplieant (PleasL.~ .~,. ~'~~ Date: Receipt: Total: Test-i~t~,4~eady: Pumped: I Date Pumping Certification Atmched~Y)~ (N)