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·. ,~.OW-~ITY USE ONLY : By: _ 1Zonin~ yalidatibn: IDate: MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St. NE - Room 132 Salem, Oregon 97301 8:00am4:3Opm Phone 588-5147 24 hr. Inst~tinn LIn~ 373-44~/ FAX 588-7948 SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION 1. LOCATION OF INSTALLATION 2. CONTRACTOR INFORMATION nath2~renB usincst~s Name & N.ml:er 3. FEES ** F~s include DEQ Surcharg~ ($30.~0) Site Evaluation, Single Fatal{ Site Evaluation, Single FanaH Site Evaluation, Commercial, first 1000 gallons Phone No. Phone No. Phone No. MaiLing Addlr~s Mailing Add~s .320.00 Site Evaluation, Commercial 1000 - 5000 Site Evaluation, Rural Area Variance. Constmedon Permit or Commercial Major Repair, first Standard System ............................. Aerobic System ......................... Capping Fill System ............................ Cesspool Disposal Trench in Saprolite ............................ Evapotranspirafion-Ab sorption System ..................... Gray Water Disposal Sump Pressure Distribution System ................ Redundant System ................... Sand Filter System ............................. Seepage Pit Seepage Trench ................. Tile Dewatering System ........................ Construction Permit or Commercial Major Repair, over 1000 gallons: Commercial Plan Review 600 gallons - 1000 gallons ........... 1000 gallons - 2500 .320.00 + $90/500/gal 320.00 382.00 .......... 593.00 .382.00 .382.00 ....... 218.00 .......... 190.00 .......... 550.00 .382.00 .703.00 ........ 312.00 ............ 382.00 ............................ 382.00 ...................... 550.00 + $100/500 gallons ~a Permit Fee + $25/500 gallons .$251500g~lons Commercial Minor Repair ............................................................................................................................................... 173.00 Single Family Dwelling, Minor Repair (tank only) ......................................................................................................... 130.00 Single Family Dwelling, Major Repair (drainfiald) ........................... 0.00 Residential or Commercial: I/ Permit Renewal, Field Visit .......... Permit Renewal No Fie d V s t ................ I 15.00 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 *po~Do~s Siphon ....................................................................................................................... 2S.00 Pumper Track Inspection, Ea Additiorml Vehicle ...................................................................... : ............................... :::::::40:00 Receipt:. Test Holes Ready: Dale Tank Pumped: -- Pumping Certification Attached: (y) (N)