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MARION COUNTY BUILDING INSPECTION <br /> Senator B~dg, NO, 225 <br /> 220 High Street NE <br /> Salem= Oregon 97301 <br /> <br />~ece,ved e~ fC_!ty Setback Req_uirem~en_ts <br />ZoningCity at Or'¢~,_~/'___ [Front 2-/~ ! Rear <br /> / <br /> <br />~t <br /> <br />BUILDING [] <br /> <br /> SEPTIC [~ PERMIT APPLICATION <br />Property O~vner ] Phone Mailing Address T~-'¢¢ ~'/ /'~'~ <br /> <br />Job Address / Site No Cross Street <br /> <br />Subdivision <br /> <br />~o*~'~-~m ~ Park <br /> <br /> Section ~ <br /> <br /> ~r Business Na~n~ <br /> <br />MOBILE HOME [] <br /> <br />Property Tax Lot NO <br />Lot <br /> <br />Block <br /> <br /> Sp # Total # Spaces <br />Acres:: ~ Lot Corne~// O <br /> <br />Phone ~r_~s~$ <br /> <br />2 <br /> <br />Ar0hitectcEngmeer <br /> <br />Type ot 'Permit -- ~ Tach- <br /> [] Review <br />- H~ht Of Building <br /> <br />Mobile Homo <br />Width <br /> <br />- Nevi '~--" Addition ~ Demo <br /> i ~ Relegation ~ Ccc Ohg <br /> <br /> i No Stories Sq Ft M~,in Floor <br /> .LengthM°bile Home ¢ Bedrooms <br /> <br />Sq Ft ged Floor <br /> <br />Occupancy <br /> <br />rj <br /> <br />Proposed Septic Installation <br />Previous Site Evaluation # <br />Type of System <br /> <br />__~Test Holes Ready <br /> <br />Will c_~all when holes read~ <br />Existing Septic System <br />Existing Ta_nk Size <br /> <br />Proposed Bedrooms <br /> <br />. _. Existing Orainfleld Length <br /> Type of System <br /> <br />Bate Tank Pumped:: <br /> <br />Existing Bedroome <br /> <br />Bldg Fee $__ <br />Mobile Home Fee <br />Fleet Surcharge <br />Zeroing Surcharge <br />State Surcharge <br /> <br />Plans Cheek Fee <br />Site Evaluation Fee ¢'~; ,~. O~,~- <br />Septic Permit Fee ~. <br />DEC Surcharge . (~ ~ 0 <br />Technical Review Fee <br />Reirlspectioe Fee <br /> <br />investigation Fee <br />City Fee L~/¢z/ :~'Z~ <br />TOTAL / X/. S <br /> <br />RECEIPT NO -. <br /> <br /> <br />