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F.OR OFFICE.USE ONLY <br />"Received ~ <br />,City Zoning~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br />8;00 a,m,-4:30 p.m. Phone 588-5147 <br />Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br /> ~ARij~,m~ tu~'¥ RED STRUCTURE & SEPTIC PERMIT APPLICATION <br /> <br />'[ LJ//Single Family Dwc~g [ ] O~ <br />[ ~'~S [ ] ~M [~w [ ] Smsa [ ]~.~g. [ ] Rep~m~t [ l Tec~m~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation 4. Fee Schedule <br /> <br />Au~, Agmfflt~ascc Mailing Address & Phtm~ No, <br /> <br />Ccok,~or Business N~m~ & Number Mailing Add~as & t~c~c No. <br /> <br />¢'Y/-._¥/~/ [ <br /> <br />3. Septic Information (Check where applicable) <br /> <br />lh0o~o~l No, Be~tmorns; Exist~g No, Bedmor~: New lmtallafi~ [] <br /> <br />Proposed Si~ Evaluation [] <br /> <br />'l'eg H~es Reafly [] Will Call Whe~ Tesl Holes Reaxly [] <br />Ealsfing Sit~ Evaluation [] Existing Sit~ Evaluation No: <br />prcaposed Installation Permit [] <br />mlsmag Septic Sysu~ra [] <br />F. xls'fin g l)tailffteld Leash: Tank Si:c: <br />Dam Tank Last Peml~xh <br />Pumper Form At,,achext [] <br /> <br /> / <br />[ 4' I have ~ad this application in its entirety and certify that the s~ated ixfforamti~ i~ true and <br /> <br />[ 10~er <br />[~I agree to build according to the submiJ;I~d plans and apccL,Sica~oas, the-laws of th~ <br /> <br /> stem of Oregon md the ?~,in~m~s of Marion ~atmty. <br />Signature of Applicant <br /> <br />A, Each Mfg,'d Home or Modular Unit <br /> Base Fcc <br /> Each Mfg.'d Home or Modular Unit <br /> <br /> Water/Sewer Conn~tion Fee <br /> Electrical Service <br /> <br /> (I) Total of Above Fees <br /> (2) 5% State Surcharge (.05 x Al) <br /> O) Zoning Surcharge (,05 x Al) <br /> Subtotal <br /> <br /> Mfg.'d Structure Storage Fee <br /> Mfg,'d Structure Storage Renewal <br /> <br />C. Site F. valuation Fee <br />D, New Seplic Installation Permit Fe~ <br />E, AuLhodzatico Notice Fee <br /> <br />F, Repair Pen'nit Fee <br /> <br />G. On-Site Technical Review Fee <br /> <br />I, Reinsp~tion Fee <br /> <br /> (jr~ $40,00 per hour (2 hour min,) <br />K. City Fee <br /> <br /> TOTAL AMOUNT DUE <br />RECEIPT NO. o~I 3~ <br /> <br /> Item x Cost = Total <br /> <br /> / <br /> / .'~7'~,..~g: ~' <br /> 25,00 <br />__ 35.(X~ <br /> <br /> ,.L/1/. lC, <br /> <br /> 25,~ <br /> <br /> <br />