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Received ~y;L~/~ ~A~IC~'I~OUNTY BUILDING INSPECTION <br /> <br />Date: .... ~ Phone 688-5147 <br /> BU~Orfi~ ~E HOME ~ <br /> Phone: Mailing <br /> <br /> Job Address;/ , ~ ' , <br /> /~ ~--~ ~; ~ V~ SiteNo,; <br /> <br /> City Setback Requirements; <br /> <br />; <br /> <br /> Left <br /> <br />Proper~y Tax Lot NO.; <br /> <br />SEPTIC ~;~ PERMIT APPLICATION <br /> <br /> / <br /> Cross Street; <br /> <br /> Fleet BIO Zone: <br /> <br />Subdivision: <br /> <br />Mobile Home Park: <br /> <br />Lot Width; <br /> <br />Lot: <br /> <br />Sp, #; <br /> <br />Block; <br /> <br />Total cf spaCes,. <br /> <br />Lot Depth: <br /> <br />Range: <br /> <br />Acres: <br /> <br />Irreg. <br /> <br />Map: <br /> <br />Corner; <br /> <br />IContractor Business Name and No.; <br />ArchitectTE~ -- <br /> <br />Phone; <br /> <br />Phone; <br /> <br />Address: <br /> <br />Address: <br /> <br />Type of Permit: I New; ~ Addition: [] Demo: [] Tach. Use of Building; RES ~ <br />;.-.-.-.-.-.-.-.-.-~./~'?"/~2 / Alter; [~ Relocation: [] Ccc, Chg.: [] Review: [] COM ~ <br />Height of Building; No, Stories; Sq.. Ft. Main Floor; Sq, Ft, 2nd Floor; Sq. Ft. Garage: Ofher: <br /> <br />Mobile Home Mobile Home # Bedrooms; Occupancy: Occupant Load; Water S,q~ly; <br />Width; Length; ~/'~, / ~ <br /> / <br /> $ <br /> <br />Proposed Septic installation: <br />Previous Bite Evaluation cf; ~ ~ ~-~""~ <br /> <br />Type of System; <br />Test Holes Ready: <br /> <br />Will call when holes ready: <br /> <br />Existing Septic System; <br />Exisrin~_Tank Size; <br /> <br />Proposed Bedrooms: <br /> <br />.... Existing Drainfield Length; <br />Type of System; <br />Date Tank Pumped: Existing Bedrooms: <br /> <br /> I have read this application in its engrety and oergfy that the stated information is <br /> true and correct to the best of my knowledge. <br /> I am perforrniog wOrk on a preped'y I own or occupy. <br /> I am a registered builder OR ( ) the authorized representative of a registered <br /> builder, <br /> ) The work will be performed by a registered builder. <br /> ) Other <br /> <br />OTHER PERMITS REQUIRED BY THiS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MC lS-6 <br />Rev. 12/67 <br /> <br />Valuation: <br /> <br />Bldg. Fee; <br /> <br />Mobile Home Fee: ................ <br /> <br />Fleet Surcharge: <br /> <br />Zoning Surcharge', <br /> <br />State Surcharge; <br /> <br />Plans Check Fee: <br /> <br />Site Evaluation Fee: <br /> <br />Septic Permit Fee: <br /> <br />DEQ Surcharge: <br /> <br />Technical Review Fee; <br /> <br />Reinspection Fee: <br /> <br />Investigation Fee', <br /> <br />City Fee: , <br /> / .-~-?~-~ ~ <br />TOTAL FEE; <br /> <br /> <br />