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zen g va da on .~L~....~-------~..--~ .... . ~e '~" st.~ ,[ ~ _ ~ ~ ~_ _~_~ ~ <br /> , , / / ' Salem, Or~on 9730 ~ Left ~/[ Right ~/ [ <br /> <br /> Phone: <br /> <br /> Site NO.: <br /> <br />Subdivision: <br /> <br />Mobile Home Park: <br /> <br />Section: <br /> <br />Lot <br /> <br />;¢,~ ~ ;-;~- '- '- Cor.er: <br /> <br />Property Tax Lot No,: <br />q 74H <br /> <br />Sp ~: <br /> <br />Contractor Business Nam and No,; <br />,~r~'[~[~e~hginee~T----~ ........ <br /> <br />New: L~ AddltiOrl: Demo: F~ Tach. <br />Alter: ~ Relocation: [] Occ. Chg.: (~ Review: <br /> <br /> Building: No. Stories: Sq, Ft, Main Floor: Sq. Fl, ~nd I <br /> <br />Mo~il~ ~r'n~- Mobile Home <br />Width: ~ Length: <br /> <br />Proposed Septic Installation: <br />Previous Site Evaluation #: <br /> <br />__TFpe qf_~y.~!~m! ............................................... <br />Test Holes R~d×i ........................ <br />Will cell when holes ready: Proposed Bedrooms; <br />Existing Septic System: /'l/f ............ <br /> <br /> Existing Drainfield Length: ~ ~ .~ ~ <br />~T~¢e oLSZ~t¢~ ......~~. ~%.,.~ <br /> Bate ~ank Pumped; '~ <br /> <br />__E~xistin~g~B_e._d_ro_o_.m_5_:_ J <br /> <br /> } Other <br /> <br />SIGNATLJRF_- OF APPLICANT: ~--.~_~ .~_ ~, ~/ <br />OTHER PERMITS REQUIRED BY THIB DEPI: PLUMBING, MECHANICAL, ELECTRICAL <br /> <br /> Fleet SIC Zor~ <br />· ei~ .... <br /> <br />Use of Buiid)ng:/~ <br />gq, Other: <br /> <br />RES ~' <br /> <br />COM [..J <br /> <br /> W~.S pply: <br /> Load: ~ <br />Valuation: $ ,/~ ~--~)--.'. ~-~ <br /> <br />Fleet Surcharge; <br />Zoning Surcharge: ~ <br />State Surcharge: ] ' <br />Pla., Oheo F e: .... L-g, <br />Site Evaluation POe: <br />Septic permit Fee: <br />BEQ Surcharge: <br />Technical Review Foo: .......... <br />Reinspection Foe: <br /> <br /> .~. ,-- <br />City Fee: <br />TO~^L PEE: z-~c~-.,..-~.b~ <br />RECEIPT NO.: <br /> <br /> <br />