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FOR O~ FFICE USE ONL%,~ MARION COUNTY BUILDING INSPECTION FOR OFFICE USE ONLY <br /> · ~. 220 High Street NE -- <br /> <br /> ~/~/.. -?-- ~ /¢:~,~4:30p.m, Phone588-5147 kront; /~'{ Heer; /41 <br />Date: 7/~/~/ .., "~ ~d~hone 588-7g04 I <br /> / r ~ ~ /~ 588 794n Left Side: / ~ Righ[ Side: /~ <br /> .~~ · <.~/~, //ff -~ ,%.., ¢~ <br /> <br /> ~AN~~ST~0~E & SEP~C PER~IT APPLICATION <br />  [~ Si~leF~flyDw~g [ ] O~&~¢O~ C~m [ ] S~o '" <br /> [~S [ ICOM t~New [ ]Sm~e [ ]~.~, [ ]R~ment [ ]Techni~Rev~w <br /> <br />COMPLETE ALL SECTIONS, 1 'IHROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation <br />Au~, Ag<~ MM~g A~ms & ~ No. ' <br /> <br />[~ffI have read this application in its entirety e. tlcl c~y ~at ~* s~d ~mfi~ is ~e ~d <br /> <br />[ ~ I agree to bu~ a~oMing <br /> <br />Signature of AppU~nt <br /> <br />4. Fee Schedule <br /> <br /> Item x Cost = Total <br />A, Each Mfg. M [.tome oe Mod[dar Unit <br /> <br /> Each Mfg.'d Home or Modular Unit <br /> <br /> (l) Total of Abova Fads $ <br /> (2) 5% S~ate Surcharge (.05 x A 1) <br /> <br /> Subtotal <br /> <br />B, Mfg,'d Structure Storage Fee <br /> M£g/d Stmctue~ Storage R~ncwal <br /> <br />C, Site Evaluation Fee <br />D. New Septic I~$tallation l~ct~yt[t ]Fee <br />E, Authorization Notice Fee <br />I:, Repair Permit Fee <br />G, On-Site Technical Review Fee <br /> <br />H, Investigation Fee (il' required) <br /> <br /> @ $40.00 per hoer (2 hour min.) <br />K, City Fee <br /> <br />TOTALAMOUNTDUE <br /> <br />25.fX} <br />25.00 <br /> <br />40.00 <br /> <br />RECE[I'T NO,.(~/~ <br /> <br /> <br />