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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 />I am a registered builder OR ( ) the authorized representative SIGNATURE Of APPLIDAN ~--~ <br /> <br />; dWN~:I':E; 04//24/92 :T:tME.''t0 .*20,+ 42 : T~X L6~: ' ~A~EGORY; <br /> ~E~A, LOU <br />: SITUS ADDRESS'. CONSTRUCTION TYPE; ' OCCURANCY: <br /> <br /> AUNSVI LLE OR 9'7325 ~ , <br />~U~ OF BdiEOl~: ~AR.tON COUN'f:Y: NO <br /> <br />MAil. lNG AbDRE~S: ~-~-- ~OeBIvisI'ON: <br /> <br />REST L)EN'T LA.r <br /> <br />PHONE: <br /> VALUA'[' iON; <br /> E~L O~Ki SECTION: TOWNSHIP: RANGE: ZONE: ' MAP: <br /> <br />;WIDTH: <br /> <br />:DEI:~H: AF~EA'. U~l'~: , iRREG. LOT: : CORNER: <br />P ~i 5., A~ ~O <br /> <br />5t <br /> <br />'TYPE: ON-SITE SEWAGE <br /> <br />PERMIT' OR APPLICATION NO: <br /> <br />CON'T'RAC'f'OR, NO_ <br />~A, LOU <br />SA~E <br /> <br />P~ONE: 7~9~'1011 <br /> <br />9039583 <br /> <br />WATER SUPPLY: PW <br />'f~'f' HOLE~ READY: <br />S~I'E EVALUATION NUMBER: <br />EXISTING TANK S~ZE: lO00 <br />EX~S'I'~NG DRAIN FIELD LINES: <br />SEP'f'~C TANK PUMPED: <br />PREVIOUS NO, BEDROOMS: 0" <br /> <br /> l 'T' ENI ~"l. <br />EXiS'fING SYSFEM EVAL- <br /> %,- <br /> <br />"f'O~AL A~E~_D FEES <br />PRE¥IOUS RECEIPTS <br /> RECEIPT <br /> <br />QUANTI"fY ,&N~UN'T' <br /> 1 $130.00 <br /> <br />$130.00 <br /> $o.oo <br />$!30,00 <br /> <br />BALANC~ DUE $0_ O0 <br /> <br />PAYED: IqEZA, L~ RECEi.'"' Pl NO; ¢1532 <br /> <br /> RECEIVED BY: mb 'IYPE: CK CHECK ~: 56?2 <br /> <br /> SEE A'f'fACBEO DOCD~EN'f FOR RE~UIRE~.8:N'I'S OF ON-SiTE SEWAGE SYS'f'E~. <br /> <br />$ THIS IS NOT A PER!MiT. THIS APPLiCATiON f.4tJST GO THROUGH A REVIEq4 PROC~ ~NIdERg THE <br />FOLLONING INII. JST B6 COMPLETED. IT IS THE RESPONSIBILITY OF ~HE A~PLICANT TO AS,'.'.'.'.'.'.'.~JRE THAT <br />ALL NEC~RY 1NFOR$,tATION H.&.~. BEEN ~ROVIDED. <br /> <br />PLAN RE'VIEN: 8Y,,~...~OAT E .....................................¢'~,,.,~.,/'~.. CZ 'FY JUR]SD iC'f'i~: BY ............................... DAlE .................... <br />REMARKS: EXIS']'iNG SYSf'EM ~VAL FOR PARTi'f'1~NG <br /> -, · <br /> <br /> OFFICE COPY <br />PORM # MD 15-58 REV, <br /> <br /> <br />