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F6" OmCE USE O.'V <br /> <br /> v.....ig <br /> <br />MARION COUNTY BUILDING IhI~P~EC.TION <br /> <br /> Salem OR97¢..~,~~ '= L, 2 L,~ lJ ~j <br /> <br />FOR OFFICE USE ONLY <br /> <br />/O/ <br /> <br /> MANUFACTURED STRUCTURE & SEP~{~ P~T%&~:?~ATION <br /> <br />[ [-( Single Family Dwelling [ ] Office [ ] ClasSloom [ ] Stm'age <br />[L~"P~S [ ]eOM [}~ew [ ]Slot'age [ lO ce. Chg. [ ]Replacement [ ]TechmcalReview <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />I. I_~catlon of Insl~llatlon <br /> <br />Mo~le~oeae Park <br /> <br />2, Installation <br /> <br />Co~wactorBos~esssName&:Nn~bcr .[AailmgAddwaa&PhoneNo, ~- 7 7q¥/ <br /> <br />3. Septic Inlonnatlon (Oheek ~t~ere apDIleaDl~) <br /> <br />l'm~osea No Bedrc~m: Eamung No. BMiooms;; N¢'~ lnstallalic~ [] <br /> <br />Prol~se. cl Sit~ Evaluafioal [] <br /> <br />Test Hdm Ready [] Will CaE When Te~'t Hole~ Ready [] <br />Eyastmg Site Evaluation [] Existing Sate Evaluauon No; <br />Proposed In~lalla~oa ptm'~t [] <br /> <br />ll~al,,M~lg Dr~dnfield Iamgth: Tank Size; <br />Date Tank Last Pumped- <br /> <br /> ~nn Attuned [] -- <br /> <br /> read ~s apphcafi~ m its entry ~d ¢e~ ~t ~e s~ ~fi~ is ~ ~d <br /> ~m~ to ~c ~t of my ~owlMge. <br />I ~ffo~mg w~ ~ a ~ I o~ or ~py. <br /> <br /> wo~ will ~ ~d~ by a ~gi~¢~ ~dcr <br /> <br /> agm¢ to build a<ording~ ~e su~itmd pl~s ~dfic~s, me h~ ~ <br /> <br />Fee Schedule <br /> <br />Each Mfg,'d Ilome or Modular Unit <br /> <br /> (1) Total of Above Fees <br /> (2) 5% State Surcharge ( 05 x Al) q, / <br /> (3) ~mg Surcharge (05 x A I) <br /> Subtotal <br /> <br />Mfg'd Structure Storage R~c~al 25 <br /> <br />hwcstigati~ Fee (if r~uired) <br /> <br /> ~ $40 00 per hour (2 hour mtn) <br /> City Fee <br /> <br />TOT&L AMOUNT DUE <br /> <br />40 00 <br /> <br /> <br />