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[. FOR CITY USE ONLY <br /> Received By: __ <br /> <br />__Zorfin~Validation: <br /> <br />/Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:3Opm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />1. LOCATION OF INSTALLATION <br /> <br />8~visioa Lot Block No. E~loy~es <br />~cfion ~ ~ Tomhip ~ ~ ~n~ / ~ ~ne Map Wmr S~ly: <br /> ~vate Well <br />Lot Wid~ ~t~ Ae~s ~,~ ~eg. La ~m~ Co~i* W~ll <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />3. FEES <br /> <br />Mailing Ad~s' - I Phone No. <br /> <br />** Fern ~clu~DEQ 8umharge ($30.00) ~( ..~ f'~"'-] L['~ <br />Site Eval~fion, Sidle Fmily Dwell~g, f~st lot ................................................ 21.~.......~1.~ ............ $320.~ <br />Site Evalmfion, S~Ie F~ily Dwells, ~ addl lot ......................................................................................................235.~ <br />Site Eval~fion, Comme~al, flint 1000 gfllons ............................................................................................................. 320.~ <br />Site Eval~fion, Commemial 1~0 - 5000 gallons .................................................. ~ ................................. 320.00 + $90/500/~ + $1~/5~ gallons <br />Site Eva~tion, ~ ~ea V~ee .............................................................................................................................. 320.~ <br />C~ion P~~ajor ~ff, ~ 1 ~0 gallons: ..................... ~ <br /> ..................... ~ Z~ Z ~ ZZ~ ZZ~ 2 ~ Z Z Z ~ Z Z~ Z '.~ Z.~ Z~ Z ~.~.~.;'.~..~ ......... ',.....2,....21s.00 '. <br /> Ca~ing Fill S~tm .......................................................................................................................... 593.00 <br /> Ces~ool ................................................................................................. ~ ........................................... 382.00 <br /> ~1 T~nch in Sapm~te .............................................................................................................. 382.00 <br /> Eva~imfion-Abso~fion Sys~m ............................................................................................. 218.00 <br /> ~y Water Disp~M Stop ............................................................................................................... 190,00 <br /> P~s~e Di~bution System ............................................................................................................. 553.00 <br /> RedaCt System ............................................................................................................................. 382.00 <br /> Sand Filer System ............................................................................................................................. 703.00 <br /> S~age Pit ......................................................................................................................................... 312,00 <br /> Se~ge T~nch .................................................................................................................................. 382.00 <br /> St~p Slope ......................................................................................................................................... 382.00 <br /> <br />Single F~ily ~elli~, M~or R~r (~ only) ......................................................................................................... 130.00 <br />Single Fmily ~elli~, Major ~ (~nfield) ........................................................................................................ 210.00 <br /> <br /> Receipt:. Total: <br /> <br /> Test Holes Ready: <br />Date: /~'-~ 7' Tank Pumped: <br /> <br /> Pumping Certification Atmche~ <br /> <br /> <br />