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· FOR OFFICE USE ONLY <br /> <br />Da..= ¢,,/.-/! <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> <br /> Code-A-Phone ~:;1~04 <br /> <br />FOR OFFICE USE ONLY <br /> <br /> MANUFACTURED STRUCTURE & SEPTIC <br /> .... B NG tNSI: _ t <br />l[/4'~SingleFamflyDwellmg [ ] Offi~ [ ] ~s~m [ ] S~mge <br /> ]COM ~ew [ ]S~mge [ ]~.~. [ ]R~ment [ <br /> <br />] Technical Review <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1, Location of Installation <br /> <br />Installation 4. Fee Schedule <br /> <br />Au~h,, Agen~ ~ <br /> <br />Contractor Business Name & Number Mailing Addms~ & ~none No. ~7d q~ 7 ~ ~, <br /> <br />3. ~lc In~n (Ch~ w~ ~l~e) <br /> <br /> No B~vJm~ms:: Bxistmg No~ Bedrooms;: New Inmllafion [] <br /> Site Ev~uafim <br />T~R~ <br /> <br />g~ting Se~c Syst~ [] . ~ <br />F.x~'~g Dnu..tfi~ Length~ Tea~k Size: <br /> <br /> Tank Last <br /> <br />Pumper Form Ammhed [] ' <br /> <br /> I have mad ~is a~h~fi~ ~ i~ ~fi~ and ce~ ~at ~e smmd ~fi~ is ~o ~d <br /> mrna m ~e ~[ of my ~owl~ge, <br /> I ~ ~E~ng w~ m a ~ I own or <br /> I m a ~m~ ~d~r OR [ ] ~e aU~O~ ~mmfivc of a m~m~ b~r. <br /> <br /> O~er <br /> <br />[ ~' I agree to build aoaorOang to the sulxnittcd plans and ~d~s, ~e hw~ ~ <br />Signature of A~h~nt . <br /> <br />B Mfg 'd Structure Slorage Fee <br /> Mfg 'el Str0ctum Storage Renewal <br />C Site Evaluation Fee <br /> <br />I) New Septic Lq~l~ilation Permit Fee <br /> <br />P Repair Permit Poe <br /> <br />Et, I~vestigation Fcc (if reqtlxmd) <br /> <br /> ('o3, $40 00 per hour (2 hou' min) <br />K Crt3 Pee <br /> <br />TOTAl. AMOUNT DUg <br /> <br />25 O0 <br />25 O0 <br /> <br />---- 4000, <br /> <br /> <br />