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BUILDING <br /> <br />Pr ty Owner: <br /> <br />Job Address: <br /> <br />MARION COUN;'[Y BUILDING INSPECTION <br />$~latOr Bleg, NO. 22; <br />220 High St~et NE <br /> Salem, Oregon 97301 <br /> <br /> Phone 588-5147 <br /> Code-A~Phone 4:$0 P.M. - 8:00 A.M. <br /> <br /> 'MOBILE HOME [] SEPTIC [] <br /> <br />Subdivision; <br /> <br /> '~;it~ Setback Requirements: <br /> Front ~.~ Rear:~,~-, <br /> "Le~-- -- - ! Right .~ <br /> I Side,. ,~ Side: ~ <br /> <br />PERMIT APPLICATION <br /> <br />Phone: Mailing Address: <br /> <br />Site No,; <br /> <br />Property Tax Lot NO,; <br />Lot; <br /> <br />Cross Street; <br /> <br />Fleet S/C ~- <br /> <br />Block; <br /> <br />Mobile Home Park; Sp. ~¢; Total ~¢ Spaces: <br /> <br />Section: <br /> <br />Range: <br /> <br />Lot Width: Lot Depth: Acres; Irreg. Lot: <br /> <br />1 Map; <br /> ,,, Corner/~ <br /> <br />IConic,actor Business Name and No,; I Phone: <br /> Phono: <br />Architect/Engineer: <br /> <br />Address; <br /> <br />Address: <br /> <br />Typ~ oi ¢;~rniil N'~w:" '~ Addition: [] Demo: <br />~J'~r'u~.~,o~) Alter:~ mlocatlon; <br /> <br />Height of Building: No. Stories; Sq. Ft. Main Floor: <br /> <br />Mobile Home Mobile Home ~ Bedrooms: <br />Width: Length; <br /> <br />Tach. <br /> <br />Review: <br /> <br />Sq, Ft, 2nd Floor: <br />Occupancy: <br /> <br />PropoSed Septic Installation: <br />Previous Bite Evaluation //~; <br /> <br />Type of System: <br /> <br />Will call when holes ready: <br /> <br />Proposed Bedrooms: <br /> <br /> Existing Septic System: <br /> Existing Tank Size: <br /> Existing Drelnfield Length: <br /> Type of System'. <br /> Date Tank Pumped; Exlstlr!~ Bedrooms: <br /> <br />(/I have read this application in its enbrety and certify th~ the stated irdor n~aSon Is <br /> ue and correct to the best of my knowledge, <br />( ~,w')"'"4'r:m perforrning work on a property i own or occupy, <br />( '/,/¢ I;.~ ~ registered builder OR ( ) the authorized representative of a registered <br /> <br />( ).,,.~her <br />( ,~ .I,_agreeto butld acCOrdlng to the stlbmlS'ed plans and specifications, theJawSOf the st ate °f Oreg°n and the~:?riTtJnt?,, ~__,/~;;~ <br /> <br />OTHER PER~ITS REQUIR~ANIcAL, ELECTRICAL <br />MC 1g-6 <br /> <br />Use ct Building: :-"RES ' '--~~'; <br />~q,'R, Garage: I Other: <br />Occupant Load; Water ~upply: <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 />P ans Cheo <br /> <br />Reinspeotlon Foe: <br /> <br />investigation Fee: <br />City Fee: <br /> <br />TOTAL FEE; <br /> <br />RECEIPT NO,; <br /> <br />Site Evaluation Peet ............. <br /> <br />Septic Permit foe: <br /> <br />DEQ Surcharge: <br /> <br />Technical Review Fee; <br /> <br /> <br />