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Rsceive~ S'~; .... ~ ' /l~l~l~J~ BUILDING INSPECTION <br />Zonng Va da on;..~ ~ ~ 22~lgh~treetNE <br /> <br />Oats; Q/.~~ P~o.e 588-514~ <br /> / ( ~ ¢ ~ ,, -~, .C~A-Phone 4:30 ~M. - 8;00 A.M./ <br /> BUILDI~j~BiE~E ~ SEPTIC ~ PERMIT APPLICATtON <br /> <br />Address: <br /> <br /> Ci~YFront:ft Setback Requiir. e_men__tS:Rear:Right <br />Iside: / side: <br /> <br />Site No,: <br /> <br />Property Tax Lot NO.: <br /> <br />Subdivision; Lot; <br />Mobile Rome Park: Bp. #; <br /> <br />Zo.e: <br />Irreg. Lot,.~ ..... Corner: <br /> <br />'~'"-/ L-,~,rchltect / Engineer: ~. Ph6n~; _ ' <br /> <br /> Address: <br /> <br />IAddress: <br /> <br />Type of Permit: New: <br /> Alter: <br /> <br />~ Addition: [] Demo; [] <br />[] Relocation; [] Occ. Chg.: [] <br /> <br />Tech. <br /> <br />Review: <br /> <br /> Height of Buildi.ggl Ne. Stories: Sq, Ft. M.._~in Floor: Sq.~loor: <br /> ,, <br />-~<~blle Home Mobile Home ¢ OccupancY'. <br />Width: ~¢- Length; ~ <br /> <br />Use of Building: t ~ , I RE~ <br /> <br />S~t~Gsge: Other; <br />Occupant Load; Water Supply: <br /> <br />Valuation; $ <br /> <br />Proposed Septic Installation; <br />Previous Site Evaluation #: <br />Type of System; <br />Test Holes Ready; <br />Will call when holes ready; Pr~[~osed Bedrooms: <br /> <br /> Existing Septic System: <br /> <br /> Existing Drelofield Length: <br /> <br /> Date Tank Pumped: '7-- ~- - ~-, <br /> <br />{ ¢1 have re~d this applicatio~ in ils ongrety and oerpfy that the stated information true and correm to the best of my kn~ledge. <br /> <br /> I em a registered builder OR ( ) the authorized representstive of a registered <br /> <br /> The work will be performed by a registered builder, <br /> <br />$10NATURE OF APPLICANT', - <br /> <br />OTHER PER~ITS REQUIRED BY THIS~EP[: PS.BIN6, MECHANICAL, ELECTRICAL <br /> <br />Bldg. Fee: $_ <br />Mobile Home tee; <br />Fleet Surcharge: <br />Zoning Surcharge'. <br />State Surcharge; <br />Plans Check Fee: <br /> <br />Site Evaluation Fee; <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 />RECEIPT NO,: <br /> <br /> <br />