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Received By <br /> <br />C~ty. . <_/.~ <br />Zoning Vahdaaon .... <br /> <br /> BUILDING [] <br /> <br />MARION COUNTY BUILDING INSPECTION <br />Se~lStOr Bldg. NO,, 225 <br />220 High artec4 NE <br /> Salem, Oregon ~TS0t <br /> <br /> Phone $88-$'J47 <br /> Co0e-A-PaOne 4:30 PM. - 8:00 AM. <br /> <br /> MOBILE HOME [] SEPTIC J~ PERMIT APPLICATION <br /> <br />tit..y.~Set ,b.~a.c,k~ ~R,e q u ir e m e~n t s :: <br /> [ <br />L.o. nt ~ ~ Rear <br /> <br />Left .... ~ R~ght <br />L Side:: ~ ~ Side <br /> <br />Property Owner <br /> <br />Job Address <br /> <br />Phone I Mailing Address <br /> <br /> Cross Street <br /> <br />Site No <br /> <br />- ~ u bd-ivisi°n j~- jL i~ ~ <br /> Mobile Home Park:; <br /> <br />-Tew&an p <br /> Lot Depth:: <br /> <br />-C~cior Business Name and No <br />Arehilect/Engineor' <br /> <br />Property Tax Lot No :: <br /> <br />Lot <br /> <br />Sp # <br /> <br />Fleet S~C Zone <br /> <br />Block <br /> <br />Total # Spaces <br /> <br />Range <br /> <br />Irreg &ct <br /> <br />. Map:: <br /> Corner:: <br /> <br />Phone <br /> <br />Address <br />Address:: <br /> <br />O~7._ <br /> <br />Type Of Permit <br />d o W":~-. <br /> <br />New' --~,. Addition ~ Demo [] Tach <br />Alter [] Relocation [] Ccc cng ~ Review:: [] <br /> <br />~ of Building No Stories <br /> <br /> ~ Home M~bii~ Home <br /> Width:: Length <br /> <br />Sq Ft Main Floor <br /> I, :5 's '/ <br /> <br /># Bedrooms <br /> <br />Sq Ft 2nd Floor <br /> <br />Occupancy:: <br /> <br />Use of Building:: <br /> <br />RES ~ <br /> <br />-~fo~poSed Septic [nstaJJation _ <br />J Previous Site Evaluation # I ~ ¢ ~ ~ <br />~_~ype 0f System ~-b~ ~ <br />/ Test Holes Ready <br />E~II when holes ready Proposed Bedrooms <br />~__ Existing Dr~infi~ld Length <br />~ Type of System <br /> <br />Existing, Bedrooms:: <br /> <br />SIGNATURE OF APPLICANT <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MC 15-S <br />Rev 12787 <br /> <br />COM [] <br /> <br />Valuati0n:: $ .... <br /> <br />Bldg Fee $. <br />Mobile Home Fee <br />Fleet Surcharge: <br />Zoning Surcharge <br />State Surcharge .... <br />Plans Check Fee <br /> <br />Site Evaluation Fee:: <br />Septic Permit Fee J <br />DEQ Surcharge:: ~-~ ~ <br />Technical Review Fee <br />Reinspection Fee:: __.. <br /> <br />Inveshgation Fee _.. <br /> <br />City Fee ] 6,~ <br /> <br />TOTAL FEE --~ g / ~ <br />RECEIPT NO ¥¢¢~ 4- ¢h~ <br /> <br />Sq Ft Garage Other (' <br />Occupant Load:: Water Supply <br /> <br /> <br />