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iNSPE~TION <br /> <br /> / , · U ~ -" t Sel~m, Oregon 97301 <br /> !, ~hon¢~ 588~147 <br />°ate = ,, <br /> <br />City Setback Requir_er~ents <br />Front ~O I' ~Rear ~,) <br />Left /-[- Right <br />Side ~- Side <br /> <br /> BUlLi~I~_/~0NI~[~HOME,,~] SEPTIC [] PERMIT APPLICATION <br /> ~U~LD .;:- ............ <br /> <br />Job Address Site No Cross Street <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Property Tax Lot NO:: <br /> ~o7 s-~- ooo <br /> <br />Lot <br /> <br />Fleet B/C Zone <br /> <br />Block <br /> <br />Zone:: Map <br />Irreg Lot Corner <br /> <br />--]-Phone <br /> <br />tAddress <br />Address <br /> <br />-':t'ype of Permit~New --~ <br />Height of BuiJd~ng <br /> <br />W~dth <br /> <br />Addition ~ ,,,,,iDem~ [] <br /> <br />Relocabom ['~ Ocs Chg [] <br /> <br />Tach <br /> <br />Review <br /> <br />Sq fit ~nd Floor <br /> <br />Occupancy <br /> <br />Use of Building <br /> <br />Sq Ft Garage <br /> <br />OccupantLoed <br /> <br /> RES Iq <br /> COM <br /> <br />Other <br /> <br />-- ;17-- <br /> <br />Proposed Septic Installation <br />Previous Site Evaluation <br />Type of System <br /> TSSl Holes Reedy <br /> <br />Will call when holes ready <br /> <br />Proposed Bedrooms <br /> <br /> Ex~sting Septic System <br />_ Exist/lng "f;~nk S_Jze <br />_- Bd¢ting Drainffeld Lenglh <br /> Type Of ~ystem._ <br />~D_et~ Tank~P_u m~ed <br /> <br />Existing Bedrooms <br /> <br />Valuatio¢ <br /> <br />8[dg Fee <br /> <br />Mobile Home Fee <br />Fleet Surcharge <br />Zoning Surcharge <br />State Surcharge <br />Plans Check Fee <br />Site Evaluation Fee <br /> <br />_./O_ 5-. Oo <br />_ 7_(.7 <br /> <br />Septic Permit Fee <br />DEQ Surcharge <br />Technical Review Fee ........ <br />Reinspection Fee ..... <br />Investigation Fee <br />City Fee __ <br />TOTAL FEE <br />RECEIPT NO <br /> <br /> <br />