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BUILDING [] ~b~'LT~oUE [] SEPTIC¢ PIPERMIT APPLICATION <br /> <br />Property Owner: <br /> <br />Job Address: <br />'~O'~ <br /> <br />Subdivision: <br /> <br />Mobile Home ~rk: <br /> <br />Section; Township: Range: <br /> I io~ .~-E <br /> <br />Lot Width: <br /> <br />Lot Depth: <br /> <br />Site No,: <br /> <br />Mailing Address: Jl77 ,u, ¢,3, 71~,,J//-,~ />z.,,~4~, ~,~ <br /> I~,,~ o/~- ~ ~.~ ......... <br /> I Cross Street: <br /> <br />Property~l. ~__q:,~:~Tax Lot No.:~ <br />Lot: <br /> <br />Sp. #; <br /> <br />Zo Map; <br />Irreg'~ tot( ' [ Corner: <br /> <br />Fleet S/C <br /> <br />sleck: <br /> <br />Total ,¢ Spaces; <br /> <br />Contractor Business Name and No.: <br /> <br />Architect/Engineer: <br /> <br />Phone; <br /> <br />Type of Permit: <br /> <br />New; m Addition; [] Oemo; <br />Alter: [~ Relocation: [] Ccc. Chg.: <br /> <br />Height of Building; <br /> <br />Mobile Home <br />Width: <br /> <br />No, Stories: <br /> <br />Mobile Home <br />Length: <br /> <br />Sq, Ft. Main Floor: <br /> <br />AddreSS; ..................................................................... <br /> <br />Address: <br /> <br />Tach, <br /> <br />Review: [] <br /> <br />Sq. Ft. 2nd Floor: <br /> <br />Occupancy; <br /> <br />Use of Building: RES <br />Sq. Ft. Garage: <br /> <br />OocupantLoad: <br /> <br />Proposed Septic Installation; <br />Previous Site Evaluation #: <br />Type ,.o..f. i~)/stem; <br />Test Holes Ready', <br />Will call when holes ready; Proposed Bedrooms: <br /> <br />Existing Septic System: <br /> Existing Tank Size: <br /> Existing D r eirffield.,,.,L.e, ,ngt h; <br /> <br /> Oats Tank Pumped: ~b' ~;;2--~/'- 'E, ~ Existing Bedrooms: I i. <br /> <br />( ' ~"~ I have read this application in its entirety ~nd car tify that the stated, lnfort~atlon Is <br /> true and correct to the best of my knowledge, <br /> I am performing work on a property I own or occupy. <br /> I am a registered builder OR ( ) the authorized representative of e registered <br /> builder. <br /> The work will be performed by a registered builder. <br /> Other <br /> <br />the state of Oregon and the ordinances of Marion County, <br /> <br />SIGNATURE OF APPLICANT:~ *~-, <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT,: PLUMBING, MECHANICAL, ELECTRICAL <br />MC tS-6 <br />Rev. 12/a7 <br /> <br /> Valuation; <br /> <br /> Bldg, Fee: <br /> <br />Mobile Home Fee; <br />Fleet Surcharge: <br />Zoning Surcharge; <br />State Surcharge: <br />Plans Check Fee: <br />Site Evaluation fee; <br />Septic Permit Fee: <br />DEQ Surcharge; <br />Technical Review Fee; <br />*.Reinspection Fee; <br />Investigation Fee; <br />City Fee: <br /> <br /> TOTAL FEE: <br /> RECEIPT NO.: <br /> <br />Other: <br /> <br /> <br />