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, City ' ~ Senator Bldg. No, 225 <br /> 70ning Validation; .c~ t.~.~.L~ ..... . , !i': 220 High Street NE <br /> · ' Salem, Oregon 97301 <br /> <br /> BUlLb~ MOBILE HOME ~ SEPTIC <br /> <br />~o arty Ow r: <br /> <br />Job Address: <br /> <br />INSPECTION <br /> <br />Mobile Home Park; <br /> <br />Lot Width: <br /> <br />Section; Township: <br /> Lot Depth: <br /> <br />Site No,; <br /> <br />Left t,f/,, ~ ~R!gyt ,f /,. i <br /> <br />PERMIT APPLICATION <br /> <br />Mailing Address: <br /> <br />Property Tax Lot NO,; <br /> <br />Lot; <br /> ( <br /> <br />"~eet SIC <br /> <br />Block; <br /> <br />Total # Spaces; <br /> <br /> Sp. #: <br /> <br />Range; Z e: ' I Map; <br />Acres'· ,rre~ot'._ / Corner()~ <br /> <br />[ConEactor Business Name and No.: Phone: Addr~~ <br />Architect/B~gi~eer; Phone: <br /> <br /> New: ~ / ~dition: ~ Demo; ~ Tach, <br /> Alter; ~ Relocation: ~ Ccc, Chg,; ~ Review; <br /> Sq, Pt, 2nd Floor: <br /> <br />ype of Portal,t: <br /> <br /> Height of Suilding; <br /> <br />Mobile Home <br />Width; <br /> <br />No. Stories: <br /> / <br />Mobile Home <br />Length: <br /> <br />Sq, Pt, Main Floor'. <br /> <br />Occupancy; <br /> <br />Use of SuilCjr.-~J,~ ' ~* j- RES '[~- <br /> <br />Sq, Ft. Garage; Other; <br />Occupant Load: - Water ~pply: <br />Valuation: $. f ~O O, 0 0 <br /> <br />Proposed Septic Installation: <br />Previous Site Evaluation #: <br /> <br />Type of ~,etem; <br />Test Holes Ready; <br /> <br /> Will call when holes read~/: <br /> Existing Septic System; <br />.... Ex,!eting Tank Size; <br /> <br />Proposed Bedrooms: <br /> <br />Existing Drainfield Lan tg~[, <br />Ty.p..e, ,~! System; <br /> <br />Date Tank Pumped: Existin~ Bedrooms: <br /> <br />( ) I have read this application in its entirety and certify ~hat the stated information is <br /> true and correct to the best of my knowledge. <br />( Z.~ I em performing WOrk on a property I own or occupy, <br />{ ) I am a registered builder OR ( ) the ~uthorize¢ representative of a registered <br /> builder· <br />( ) The work will be performed by e registered builde: <br />( ) Other <br />( ) I agree to build according to the submitted plans and specifications, the lows of <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, ELECTRI(~AL <br />MC 15-8 <br />Rev 12/87 <br /> <br />Bldg, Fee; <br /> <br />Mobile Home Fee: <br /> <br />Fleet Surcharge; <br /> <br />~'oning Surcharge: <br /> <br />State Surcharge: <br /> <br />Plans Ol~eck Fee: <br /> <br />Site Evaluation Fee: <br /> <br />Septic Permit Fee; <br /> <br />OEQ Surcharge; <br /> <br />Technical Review Fee: <br /> <br />Reinspection Fee: <br /> <br />Investigation Fee; <br /> <br />City Fee: <br /> <br />TOTAL FI=E: <br /> <br />. oE,PT .o,; <br /> <br /> <br />