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Proper~ Owner; <br /> <br /> City Setback Requirements: <br /> <br />iS,de:N/// <br /> <br />R~,~D!~ ~._-~IB~LE HOME [] SEPTIC [] PERMIT APPLICATION <br /> Phone: 1 M~,iling Address: <br /> <br />Job Address; <br /> <br />Site No.: <br /> <br />Property Tax L~t No.: <br /> <br />Cross Street: <br /> <br />Fleet S/O Zone: <br /> <br />Subdivision; Lot; Block; <br />Mobile Home Park; Sp. #: Total # Spaced: <br /> <br />Lot Width' <br /> <br />Township: Range: <br />Lot Depth;/ Acres: <br /> <br />I Zone; · Map; <br />Irreg, Lot: Co r n.~-.~ <br /> <br />ICOntractor Business Name and NO.: Phone; ross; ' <br />Architect/Engineer; Phone; Address: <br /> <br />Type of Permit; New: <br /> <br />~ Addition: [] Demo: ,~ Tach. <br /> <br />[] Relocation'. [] Ccc, Chg,: F~ Review: <br /> <br />Use of Building: <br /> <br />Height of Building: No, Stories; Sq. Ft, Main Floor: Sq. Ft. 2nd Floor; Sq. Ft. Garage; Other; <br /> <br />Mobile Home Mobile Home # Bedrooms: Occupancy: Occupant Load: <br />Width: Length: <br /> <br />RES [~ <br /> <br />COM ~ <br /> <br />Proposed Septic Installation: <br /> Previous Site Evaluation Cf; <br /> Type of System; <br /> <br />Test HOleS Ready; <br /> <br />Wi, call when holes ready: <br /> <br />Existing Septic System; <br />Existln9 Tank Size; <br /> <br />Proposed Bedrooms: <br /> <br />Existing Drainfield Length: <br />Type of System; <br /> <br />Date Tank Pumped; <br /> <br />Existing Bedrooms: <br /> <br />(? <br /> <br />( <br />( <br /> <br />I dave read this application in its entirety and certify that the stated information is <br />true and correct tO,the best of my knowlegge. <br />I am performing work on a property I own or occupy. <br />~ am a registered builder OR ( ) the authorized representative of a registered <br />buiteer, <br />The work will be performed by a registered builder. <br />Other <br /> <br />I agree to b~lle according to the submit[ed ptans and specifications, the laws of <br /> <br />SIGNATURE <br /> <br />MC t5-6 <br />Re~ 12/87 <br /> <br />Valuation: <br /> <br />Mobile Home F,e~ <br />Fleet Surcharge: ~N~/ --~ <br /> <br />Zoning Surcharge: <br />State Surcharge: /~l, ! 0 <br />Plans Check Fee: 1'~/" 5 0 <br />Site Evaluation Fee: <br />Septic Permit Fee: <br />DEQ Surcharge: <br />Technical Review Fee; <br />Relnspection Fee: <br /> <br />Investigation Fee: <br />City Fee: --J~' /~' <br /> <br />RECEIPT NO,; <br /> <br /> <br />