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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: 588-5147 8:00-4:30 <br /> 24 HOUR CODE:A-PHONE: 588-7904 <br /> <br />~ am performing work on a property I ownor occupy. <br />I am a registered buitder OR the auth0ri~ed re0resentatig~ S~GNATURE OF APPt. ICANT; <br />of a registered builder. ' <br />The WOrk will be performed by a registered builder, <br />Other <br />I have read and agree to the terms stated on the reverse slde of O^TE: <br />this document. <br /> <br />!OWNER; i TAX LOT'. I d~'~{2ORY,. <br />~ PYTHIAN ECU i LOiNG ~ I COC¢~ERC iAL <br />i'~I¥(JA ADDRESS: ~ CONSTRUCTION TYPE; ~ OCCUPANCY; <br /> <br /> AU~ OR 9?002 j ~ ' <br /> J <br /> USE OF BUlLDING[ ~N0 0F <br /> <br />TYPE: ON-SiTE SEWAGE <br /> <br />PERlvli'F OR APPLICATION NO: <br /> <br />CoN'rRACrOR, NO. <br />PY'f'HiAN BUILDING <br /> <br />PHONE: <br /> <br />9040598 <br /> <br />WATER ~]AJPPLY: <br />TEST HOLE~ READY: <br />SZTE EYALUATION NUNSER: <br />EXIST~NG TANK SIZE: <br />D(IS'riNG DRA[N FIELD LINES; <br />SEPT[C fANK PU~PED: <br />PREWIOU$ NO. BEDROOMS: <br /> <br /> il'EM QUANTiI'¥ A~]OUNI' <br />S'f'O ONSI'rE SYS < lOOO GAL 1 $210.00 <br /> <br />rOTAL AS%ESSEO P'EES <br />PREY[gu8 RECEIPTS <br />FHZS RECE f PT <br /> <br />$210.00 <br />$210.00 <br /> $O.OU <br /> <br /> BALANCE DUE $0+00 <br /> PAYEE: <br /> RECEIVED BY: ¢1 ........................................... rYPE:~I~N CHECK ~: 0 <br /> SEE A'r'rAO~ED DOCUMENT FOR REOUlR~M~TS OF <br /> <br /> THiS IS NOT A PE~JT. THIS A~LI~Ti~ ~ST ~ TH~ A R~I~ P~ ~RE THE <br />~LL~iNG ~ST ~ ~PLETEO+ JT I~ TH~ R~i~ILITY' OF THE APPLi~T TO ~RE THAT <br />~L NEC~ IN~Ti~ H~B~ P~iDED.: <br /> <br />PLAN REVIEW: BY ........... ~J___._ <br />RE~ARKS: REPAIR <br /> <br />Ci'f'YJURISOICTION= BY DATE <br /> <br />OFFICECOPY <br /> <br /> <br />