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,! I~OR CITY lYSg ONLY I MARION COUNTY BUILDING INSPECTION . ~ ! COMMUNITY DEVELOPMENT CENTER * IneceivedB,,-x~,~/"~v/'~'5-P~' A ~ 285 Church St NE - Room132 ~t~~ ~' . ~'. ~' ~' ~'W'~'~' Salem, O;gon97301 IYtt~a~ 2[ll[I IZom.gVa~at~:~ '~ I 8:00am4:30pm Phone 58~5147 11~1~ ~1 IDate: [ ~ q / ] 24 hr. lnsp~tionFAX 588-7948Line 588-79~ ~ ~ ~ L ~'~ ~? SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION 1. LOCATION OF INST~LATION ~ARION COUNTY Job Address S .a v,, £ Tax Acct. No. Subdivision Lot Block No. Employees Existing No. Prop~ NO. Bedrooms Bedrooms Section /5 To--hip ~5 Range ]t~" Zone ~- ] Map ~l,~,~/~ Water Supply: Private Well ( ) Spring Lot Width &~t ~t Depth ~lO~ Acres l~eg. Lot C .... C 2. CONTRACTOR INFORMATION Properly Owner ~_ i ,~ / ~^ [~ [ n Auth. AgenVreasee /i'~ e I~CJ r Contractor Business Name & Number ' Mailing Address Ma ngAddress PboneNo ~O,~'~y(~;, 0~[~~' 3. FEES ** Fees include DEQ Surcharge ($30.00) Site Evaluation, Single Family Dwelling, first lot ......................................................................................................... $320,00 Site Evaluation, Single Family l~velling, 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 Conmaercial Major Repair, over 1000 gallons: Construction Permit Fee Commercial Plan Review 600 gallons - 1000 gallons ............................................................................................................... 133.00 1000 gallons - 2500 gallons ............................................................................................................... 133,00 Coramercial Minor Repaff ............................................................................................................................................... 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 ......................................................................................................... 115.00 Authorization, Field Visit .................................................................................................................. 247.00 Authorization, No Field Visit ............................................................................................................ 117.00 Existing System Evaluation ............................................................................................................... 247,00 "~Annual Eva[mt on)A ernat ye 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 Track 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 NameofApplicant,l~-a~.4~nt).' ~0~..~.~5..~i~ ~. Receipt: Signature of Ap~~z/~ C~~ Date: ~- ~' ~'~ Test Holes Ready: Tank Pumped: _ 7 - q ;a3e~ Pumping Certification