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Received ~ L~, t~) Senator Bldg. No. 225 L_~.~ 220 High Street NE ., % .~ [ i Salem, Oregon 97301 phone 51~8-$147 INSPECTION BU~I~,~!i~.~'~ LM~O[~U~[HOME [] SEPTIC E~PERMIT APPLICATION Property Owner: t Phone: Mailing Address: ~b Address: J ' ' J Site No,; ~C~oss Street; ..... ~ Property Tax Lot No.: ~ ~--~ Flee~ S/C Zone: Subdivision; ' I Lot: ~ ~ Block; Mobile HomeP~rk: . / ~ ~ ep.~: ' _~ Total ~ Space : : - -[ ............ ~_Ge~i°n: ~J ~ownship: ~] Range:~_~ ~ Zon~;~ ~1 Map:, ~ Lot W~dth; L~ Depth: / ~ Acres: ~ Irreg. Lot: ~ Corner: ~ ,11~~ I ISZ [ [ [ Y~ ~ C~ntra~tor,~j/,//~Su$in~se./~,,~x.~.,~,) ~Name and No.: ~'~- , ~. ~L.C_~Z~__/,~j Phone: Arahltect/Engineer; .... ~vr# H/LL~ , Address: Address: Phone; ¢.¢,.+--, % . Alter; [] Relocation: [~ Review; Height of Building: Mobile Home Ccc. Chg.; E] No, Stories; I Sq. Ft. Main Floor; Sq, Ft. 2nd Ftoor: Mobile Nome # Bedrooms; Occupancy: Use ¢ Building; R~'~'~ COM [] Sq, Ft. Garage; 1 Other; Water Supply: Proposed Septic Instellatlor,: Previous Site Evaluation #; Type ~f,.~ystem; ,~;'.~Z~'Z~.//~'z/~'~¢~' 43,/// .~ Tes~ Roles Ready; Will cai[ when holes ready: Proposed Bedrooms: ~isflng Sapac System: _ Eximing Tan~, Size: .... Existing Drainfiel~. Length: Type of System: Date Tank Pumped: Existing Bedrooms: ~ The work will be performed by a registered builder. ( ) Other OTHER PERMITO REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL Valuation: $ Bldg, Fee: $_ Mobile Home Fee; Fleet Surcharge: Zoning Surcharge: State Sureharger Plans Cheek Fee: Site EvaluatiOn Fee'. SeptlC Permit Fee: DEQ Surcharge: Techrfiral Review Fee: Reinepection Fee: Investigation Fee: City Fee: TOTAL FEE: RECEIPT NO.: