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FOR OFFICE USE ONLY <br /> <br />Received By; ~ ' <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Street NE <br /> Salem, OR 97301 <br /> <br />8:00 a.m.-4:;3Op,m. Phone 588-5147 <br />Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br />Left Side: ./~ / Right SJde:/..~ / <br /> <br /> MANUFACTURED STRUCTURE & SEPTIC PERMIT APPLICATION <br /> <br />[ S [ ] COM __w [ ] Storage [ ]OCc. Chg. [ ] Replacement [ ]TechnicalReview <br /> <br />COMPLETE ALL SECTIONS, 1 'fl-IROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation <br /> <br />Au~.Age~t/Leasee <br /> <br />Pmpose/J Installation Permit [] <br />Existing Septic Sygtem [] <br />Exi~ng ~ Length: Tank <br /> <br />Da~ T~mk Lsst ParerS: <br /> <br />4. Fee Schedule <br /> <br />A. Each Mfg,'d Home or Modular Unit <br /> <br /> (1) Total of Above Fees $~ <br /> (2) 5% State Surcha~e (.05 x Al) ~/D <br /> (3) Zo~g Sumha~e (,05 x A 1) <br /> <br /> SubtotM <br /> <br /> d Street m Storage Rcmewal <br /> <br />Septic In~tak[ation Permit Fee <br /> <br /> F, Repair Permit Fcc <br /> G, On-Site Technical Review Fee <br />I Il. Inve~tigatior~ Fee (ff required) <br /> <br /> Re~spection Fcc <br /> Other inspection~ not listed above <br /> @ $40,00 per hour (2 hotlr min,) <br /> K. City Fca <br /> <br /> TOTAL AMOUNT DUE <br /> <br />RECEIPT NO c~J~/~,~ .-- <br /> <br />40,00 <br /> <br /> <br />