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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 888-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />Iarn per¢orming work on a property I owr~ or occupy. <br />I am a regis eredbu der OR he author zed representatve <br />et a registered builder, <br />The work will be per¢ormed by a registered builder. <br />Other <br /> <br />have resd end agree to the terms stated on the reverse side of <br /> <br /> KO'f"I'RE . RAY <br />SITUS ADDRESS: CONSTRUCTION TY¢'E~ OCCUPANCY: <br /> <br />RESIDENTIAL <br /> <br /> 8612 E~'iAN SQUARE RD <br /> AUf'4SVJLLE OR <br /> <br />USE OF BUIt. DING: <br /> <br /> 5E ' Cd~ifAAC+ Cra/: <br />9?325 <br /> 1'4AR J, ON COUN :i'¥ NO <br /> <br /> 8613 SHAW ~ARE RD SE <br /> AUC,'CSV ~, LLE, OR 9?325 <br /> 364-2318 ~i'1'E NU~ER: ]0216 <br /> <br />LOT; BLOCK: SECTION: ;TOWNSHIP'. RANGE[ , ZON~: ; MAP: <br /> ~ 8S 2W AR3 , <br />WIDTN: DEPTH: A~EA~ 'UNFrS: ~REG LOT: '~NER: <br /> <br />49 <br /> <br />f'YPE: ON-SI]'E SEWAGE <br /> <br />PERM~f' OR APPLICA'T'ZON NO: 9034903 <br /> <br />CONTRACTOR, NO. <br />KOT'f RE, RAY <br />8613 SHAW S(,~ARE R,D, SE <br />AU~4SVI LLE, OR 9?325 <br />PHONE; 364-23't8 <br /> <br />WATER SUPPLY: P'N <br />'rEST HOLF....% READY: <br />Si'I'E EYALUA'riON NUMBER: iN P~E~ <br />EXIS'rZNG TANK SiZE: <br />EXISTING ORA~N FIELD L~NES: <br />SEP'flC TANK PU~PED~ <br />PREV1OUS NO. BEDROO~S: <br /> <br /> S'f'ANOARD ON-SI'IE SYSIEIVl ~/~..~ / ~- %,,---- $155 0D <br /> <br /> BAL~CE DUE ~/O' $165. O0 <br /> ~A~EE = ~ RECE J P'f' NO' 0 <br /> RECEIVE0 ~Y ~ ,~ "YPE; CHECK ~ n <br /> <br /> SEE Af fACH~B OOCU~ENf' FO~ RE~RE~EN:~'S OF ~-~Z'f'E SEWA6E S~I'E~. <br /> <br />~ TH~S ~ ~OT A PE~T. T~8 APPL~ ~ST ~ TH~ A ~ P~ ~ERB THE <br />¢~L~6 ~ST 8E ~¢LETEB; ~T ~ TME R~B~L~TY OF THE ~PPLt~T TO ~RE THAT <br /> <br />%~)%~/'~ OFFICE COPY <br /> <br />I]A l' E <br /> <br /> <br />