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MARION COUNTY B~-LDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />2'~0 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 /> [ ~,m performing work on a property I own o¢ occupy, <br /> I am a registered builder OR the authorized representative SIGNATURE OF APPLICANT: <br /> of a registered bu{Ider, <br /> The work will be performed by a registered builder, <br /> Other. <br /> I h.ave read and agree to the terms stated on the reverse side of DATE; <br />~vice LP'T'?~* ~o~ ~o qu~e 8L~ Q2 ~ rervep <br /> <br /> OWNER'. TAX LOT'. CATEGORY: <br /> <br /> SITUS ADDRESS; CON$TRUCTION TYPE; OCCUPANCY: <br /> RO'1'H, R~ER <br /> .................... ~'~[ ..... ?~CUPANT ~OAD; <br /> , CONTRACT CITY: <br /> <br /> '~'~' bF~¢~'i~'.''ERtN~'~S;~ffET :~"~"~ ~ .................. : ',~: 0~ ~0~'s: ' <br /> BEIRUT OR 97342 , <br /> ...................................... ~L~;~L ............. B~ ...... <br /> <br />RESlOENIiA <br /> <br /> SAME <br />LOT; ~H(~E.* 8541~i'k~'8 ISECTION; ~OW~SHm~'. ~, n~:E NU~ER[~[g~02222 ~,. <br /> ' ~ VALUAT~ 4 ! <br />WIDTH; ;DEPTH: : AREA: i UNITS; IRREg. LOT'. I CORNER: <br />~ z 1,, ~ . _ _ ~0 ~ _ 5~ ~05 <br /> <br />100 110 11000. SF NO NO <br /> <br />TYPE: ON-.~II'E E. EWAGE <br /> <br />PERIVliI' OR APPLICATION NO: <br /> <br />CONTRACTOR, NO, <br />ROrH. ROGER <br /> <br />PHONE., 854-3728 <br /> <br />9040604 <br /> <br />NA'1'ER SUPPLY: cw <br />TEST HOLE5' R6ADY: <br />SiTE EVALUATION NUI~3ER: <br />F_.)(IS'rlN~ TANK ~IZE: <br />~Ia'~'~.NG B~IN FIE~ LINES: <br />SEPTIC 'r~K ~PEB:~iLING LN~ <br />PREW[~S NO. BED--S: <br /> <br />PAYEE: RD'rH. K~O~ER <br /> <br />:'tOTAL 'AssE-~EU F~ES <br />PRE¥:[OUS RECEIPTS <br />rHIS RECEIPT <br /> <br />QUANTITY AMOONI' <br /> 1 <br /> <br />$130.00 <br /> $o.oo <br />$130.00 <br /> <br />BALANCE BEE $o.oo <br /> <br />iNVOiCE NO: 42636 <br /> <br /> RECEIVED BY: c'l <br /> ........................................................ TYPE: IN CHECK ~: 0 <br /> <br /> SEE A'f"f'AC,14ED ~NEN'T FOR REQUiREf~rcLNTS OF ON-SiTE SE1NAGE SYSTEJVI_ <br /> <br />* THiS IS NOT A PERI,lIT. THIS APPLIOATiON ~UST GO THROU6H A REViEH PROOFS,..% ~HERE THE <br />FOLLOHiNG f4U~T BE COI~PLETED. IT iS THE R~.~PONsIalLiTY OF THE APPLICANT TO AS,,,',',',',',',',~URE THAT <br />ALL NECE~RY iNP'OF~IATION HA.~ BEEN PROVIDED. <br /> <br />FORM ~ MC 15-56 REV, 4/90 OFFICE C0~ <br /> <br /> <br />