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FOR OFFICE USE ONLY <br /> <br />C{~ Zoning Val{dation; ~ .... <br />Date: //.~ j,..~ - c] / <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-$147 <br /> Code-A-Phone <br /> FAX $88-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />FronI; J~-/ / t Rear; <br /> <br />Left Side: /~/ ! I,,,R~ght Side: <br /> <br />MANUFACTURED STRUCTURE & SEPTIC PERMIT APPLICATION <br /> <br />[{~SinglcFamilyDwelling [ ] Office [ ] Classroom [ <br />~RES [ ICOM ~N'ew [ ] $~Orage [ lO ce. Chg. [ ]Replacement [ ]TeclmicalReview <br /> <br />COMPLb I ~ ALL SECTIONS, 1 THROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation <br /> <br />3. Septic In~n'nat~n (Check where applicable) <br /> <br />Prqx:,s~ No, Be, dr-,.~ms: Existi~ No. Bv, liooms: New Imta~afim [] <br /> <br />Propped Site Evalua~oa [] <br /> <br />Te~t Hd~ Rmdy [] W'flt C,~tl When Test [lales Rem:ly [] <br />· Existing Site Eval~o~ [] ff~is~g ~m~ Evainmon No: <br />Pr~o~aa Insmll~on Permit [] <br />Existing Septic System [] <br />FL6sdng Dr~field I,~gth: Tank Size: <br />Date Trak L~s[ Puml~d: <br />Pumper Form Attached [] <br /> <br />[~ I have read this application in it~ entirety and c~fif'y g~t thc stated informati~l is true and <br /> correct to the best of my Imowle~ge. <br /> ] I am performing work on a prc~ny I own ¢¢ ocaapy. <br /> ] Iamamgisten, alb~fld~r OR [ ]thea~thorizedrep~eacataliveofaxeglaexv~llmilder. <br />[,.4' Thc work w~t'cc perfonnegl by a registered buJ3de~. <br />&iOther <br /> <br /> . / <br /> <br />,~. Fee Schedule <br /> <br /> A. Each Mfg.'d Home or Modular Unit <br />~ Sase F~ <br /> Each Mfg,'d IIome or Modular Unit <br /> <br /> State Fcc <br /> Watet/S~wer Connection Fee <br /> <br /> ~) 5% Sram fiurchatge (,0~ x Al) <br /> (~) Z~g Sur~arge (,05 x Al) <br /> <br />B, M£g.'d St mcmre Storage Fee <br /> Mfg,'d simcture Storage Renewal <br />C, site Evaluation F~ <br />D, New Se~ie Inim~afi~ Pe~it Fee <br /> <br />F. Repair Pe~it Fee <br />O. On-S~ Techni~l Review Fee <br />H, ~vcstigati~ Fee (if ~quimd) <br /> <br /> ~ $~,00 per hour (2 <br />K. CRy Fee <br /> <br /> TOTAL AMOUNT DUE <br /> <br />RECmT NC). <br /> <br /> Item x Cost = Total <br /> <br /> / <br /> <br />__ 25,00.__ <br /> 35.00 <br /> <br />25,(D <br />25.[X1 <br /> <br />40,00 <br /> <br /> <br />