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BUILDIN~ ~,~Q~O~. ~O~E ~ SEPTIC ~ PERMIT APPLICATION <br />Property Owner; F ~'~'~%%~ ~''* I Phone: ~aillng Addressr <br /> <br />Job Address: ' Site NO.: Cross Street~ <br /> <br />Subdivision; <br /> Lotr Block', j <br /> <br />Mobile Home Park: Sp, #: Total # Spaces; <br /> Zone: Map: <br /> <br />Seotionr ,,"' Township: <br />Lot Width'. Let Depth: <br /> <br />Range: <br /> <br />Irreg. LOt; <br /> <br />Contractor Business Name and NO,; <br />Amhlteot/Englneer; <br /> <br />Phone; ~ Address: <br />Phone: Address: <br /> <br />Type of Permit: 'l New: <br /> <br />Height of Building: <br /> <br />Mobile Home <br />Width; <br /> <br />Addition: L~ Demo; [~ Tach. <br />Rek~cation: [] Ccc. Chg,: ~ Review'. [] <br /> <br />No, Stories: <br /> <br />Sq. Ft. Main Floor: <br />,¢ Bedrooms: <br /> <br />Mobile Home <br />Length: <br /> <br />Sq, Ft. 2nd Floor; <br /> <br />Occupancy: <br /> <br />Use of Building: RES <br /> COM <br />Sq. Ft, Garage:lc, b~ .... Other: <br /> <br />Occupant Load; Water Supply; <br /> <br />Proposed Septic Installation; <br /> Previous Site Evaluation ¢: <br />_T~pe of System; <br />Test Holes Reedy: <br />Will cell when holes ready; Proposed Bedrooms; <br />Existing Septic System; <br />Existing Tank Size; <br /> <br />Existing Drainfield Length; <br />Type of System; <br />Date Tank Pumped: Existing Bedrooms: <br /> <br /> I have read this application in its e~ltirety and certify that the stated information is <br /> true and correct to the best of my knowledge. <br /> ) I am performing work o~ a property I own or OCCUpy, <br /> ) I am a registered builder OR ( ) the authorized representative of 8 repi¢tered <br /> <br />Valuation: $ <br /> <br />SIdg, Fee; <br /> <br />Mobile Home Fee: <br /> <br />Fleet Surcharge: <br /> <br />Zoning Surcharge: <br /> <br />State Surcharge; <br /> <br />Plans Check Fee: <br /> <br />Site Evaluation Fee: <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MC t5-6 <br />Rev. '12/87 <br /> <br />Septic Permit Fee: <br />DEQ Surcharge: <br />Technical Review Fac: <br />Reinspection Fee: <br />Investigation Fee; <br />City Fee; <br /> <br />TOTAL FEE: <br />RECEIPT NO.: <br /> <br /> '7_q7 _ <br /> <br /> <br />