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FOR CITY USE ONLY <br />Received By:_ Dali: <br />Zoning By: City: <br />Receip~ #: Amount:$ <br /> <br /> st~PaO~ covmY SWLOma ~S~CXION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br />8:00 em - 4:30 pm 24 hr. Inspection Line 373-4427 FAX 588-7948 <br /> <br />ON-SITE SEWAGE DISPOSAL APPLICAT/ON <br /> <br /> ( ) AIt~rati0n ()Repair ()Authorization ( ) Existing Syslim Report (for loan puq~oses) ( ) Othgr <br /> <br />No. Employees: S~ating Capacity: Total # Existing B~drooms: Total # Proposed Bedrooms: ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />P~el~er:~N ~t ~a~g~ M~gAd&oss: C~: Zip: <br />Su~vision: ~ ~l~t~ ~t: Block: <br />~p: ~ ~ne: ~ P~elSee: () 8F () AC UGB:C)Y () N <br />~o~ ~ator: Water Supply: ( ) ~vali Well ( ) Co~iW Well ( ) <br /> <br />tho PROPERTY OWNER and own, reside i~ or will reside in Ibc completed stmciure and will be my own general contractor. <br />the AUTHORIZED REPRESENTATIVE OF THE PROPERTY OWNER: <br /> <br />Business Name (please prim): <br />Marling Address: <br /> <br /> Street City: Zip: Phone: <br /> <br />Business Name (please print): ~ ~'-~//~ ~ ~"~d~'~~ License #:_~/~ ~I~ <br /> <br /> Street Ciw: Zip: Phone: <br /> <br />FEES (Chn:le 1he Agp..pd~e Fee) <br /> <br />A. SITE EVALUATIONS <br />Site Evaluation, Residential, fa-st lot $ 335.00 <br />Site Evahu~on, Residen0al~ ea addnl lot $ 205.00 <br />Site Evaluation, Con~nercial, f'u~t 1000 gal $ 335.00 <br />Site Evaluation~ Commercial, 1000-5000 gal $ 335.00 <br /> + $90/500galorpari thereof above 1000gal <br /> <br />Site Evaluation, Rural Area Variance $ 335.00 <br /> <br />CONSTRUCTION PERMITS, for lhe first 1000 gallons <br />projected DSF; <br />Slmaderd On-Site System $ 400.00 <br /> <br />Aerobic $ 400.00 <br />Capping Fill $ 600.00 <br />C.~spool $ 400.00 <br />Disposal Trench in Saprolite $ 400.00 <br />Evapotranspiration- Absorption $ 400.00 <br />Gray W~ter Sump $ 200.00 <br />Pressure Distribution $ 600.00 <br />Redundant $ 400.00 <br />Sand Fillir $ 750.00 <br />Seepage Pit $ 400.00 <br />Seepage Trench $ 400.00 <br />Steep Slope $ 400.00 <br />Tile Dewaliring $ 600.00 <br />Pump or Dosing Siphon $ 25.00 <br /> <br />For more than 1000 gallons: $ 400.00 <br /> <br />+ $40/500 gal or part thereof above 1000 <br /> <br />AUTHORIZATION NOTICE <br />Field Visit Required $ 250.00 <br />No Field Visit Requlred $ 90.00 <br /> <br />ALTERATION PERMIT $ 400.00 <br /> <br />PERMIT RENEWAL <br />Field Visit Required $ 200.00 <br /> <br />No Field Visit Required $ 85.00 <br /> <br />B. COMMERCIAL PLAN REVIEW (cost of <br />plan Review is/ncluded ia permit for sys~ms up <br />to 600 gallons) <br />600 gatlons - 1000 gallons $135.00 <br />1000 gallons - 2500 gallons $135.00 <br />thereof above 1000 gal <br /> <br />PUMPER TRUCK INSPF~rlON <br />First Vehicle, each inspection $ '80.00 <br />Each Additional Vehicle, <br />each inape~tion $ 45.00 <br /> <br />EXISTING SYSTEM EVAL $ 250.00 <br /> <br />RECORDS REVIEW $ 40.00 <br /> <br />FEE TOTALS: <br /> <br />Al. Enter Total Fees from S~tion 4A $ <br />A2. Add DEQ Surcharge(S30.00) $ <br /> for each item marked in <br /> Section "A' $ <br /> Snbtotal: $ <br />B. Enter Total from Section 4B $ <br />C. Reinapection Fee, $50.0/hour $ <br />D. Hourly Inspection Rate, $50.00/hour $ <br /> Tolal Amount Due: $ <br /> <br />Name of App~cant [Please Print]: Signature of Apldicant: Date: <br />MaRh~ Address: Test Hole~ Ready: (date) Tank Punq~nl? Date: __ <br /> <br /> <br />