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' ~: ~z~ _ M_ .,~,,,O1~1 COUNTY BUILD NG NSPECT ON <br />gity , ,. <br />~oning Vdidatiom ~ ' ~ '' .... 220 High Stre~ NE <br /> ~l .~ ~ --~,~1 ~0~[~'~ ~ ~ Salem, O~gon <br /> <br />BUILDING [] MOBILE HOME [] <br /> <br />Property Owner: '~'"Phone: <br />Job Address: <br /> <br />Subdivision: <br /> <br />SEPTIC J~ PERMIT APPLICATION <br /> Moiling Address; <br /> <br /> Site NO.: Cross Street: <br /> <br />Fleet S/C Zone: <br /> <br />Zone; <br /> <br />Property Tax Lot NO,; <br />Lot: <br /> <br /> Block; <br />Mobile Home Park: Sp, ~; Total # Spaces: <br />Section; Township: Range: Map: <br /> <br />Lot Depth: <br /> <br />Irreg. Lot; <br /> <br />Lot WJdth; <br /> <br />Contractor Business Name and NO.: Phone: Address; <br />Architect/Engineer: Phone: Address: <br /> <br />Type of Permit; I New; <br />~PT / ¢_..r Alter: <br />Height of Building: <br /> <br />Mobile Home <br />Width: <br /> <br />~ Addition; [] Demo: <br />[] Relocation: [] Ccc. Ohg,; <br /> <br /> Ne..~St°ries: j <br /> Mobile Home # Bedrooms: <br /> Length: <br /> <br />Sq, Fl, Main Floor; <br /> <br />Tach, Use of Building: RES ,~ <br />Review: [~ I~f ,¢ ~ ~ COM LJ <br /> <br /> Other; <br /> <br />Sq. Ft. 2nd Floor; <br />Occupancy; <br /> <br />Proposed Septic Installation: <br />Previous Site Evaluation ¢; <br /> <br />Type of System', <br /> <br />¥¢'¢ <br /> <br />Test Holes Re~dy; <br />Will call when holes ready: Proposed Bedrooms: <br />Existing Septic System: <br />__~,xisting Tank Size: <br /> <br />._ Existing Dreinfield Lenc~th; <br /> Type. ~f System: <br /> <br />Date Tank P~,mped; <br /> <br />Existing_ Bedrooms: <br /> <br />(~/) IhavereadthisapplicationlnitsentiretyandFerttfythatthestatedinformaSonis <br /> <br />OTHER PERMITB REQUIRED BY THIS DEP'E: PLUMBING, MECHANICAL, ELECTRICAL <br /> <br />Sq. Ft. Gorsge; <br /> <br />Occupant Load; <br /> <br />Water Supply: <br /> <br />Valuation: $. <br /> <br />Bldg, Fee: $_ <br />Mobile Home Fee; <br />Fleet Surcharge; <br />Zoning Surcharge: <br />State Surcharge: <br /> <br />Plans Check Fee: <br />Site Evaluation Fee; <br />Septic Permit Fee: <br />DEQ Surcharge; <br />Technical Review Fee: <br />Relnspection Fee; <br />Investigation Fee', <br />City Fee: <br /> <br />TOTAL FEE; <br />RECEIPT NO.: <br /> <br />I <br /> ~-,OO <br /> <br /> <br />