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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 performing work on a property I own or occuBY, <br />I Am a repistered builder OR ) the authorized representative S~GNATURE OF APPLICANT: <br />of a registered bu{Ider. <br />The work will be pedormed by a registered builder. <br />Other <br />I have read and agree to the terms stated on the reverse side Of DATE: <br />this document. <br /> <br /> DATE: 0 /23/92 ' * <br />OWNER; ' TAX 'LOT: CATEGORY; <br /> <br /> ADAMS, MARK & SALLY 68962-000 <br />SITUS ADOREBS: CONSTRUCTION TYPE: OCCUPANCY: <br /> <br />~er,,) ~E'f'RO,f,'T RD S ~- i'U~B: iOCCDPANT LOAD: <br />OEf'ROi']' OR 9?342 : <br /> OE:I'ROi]: ND , <br />USE OF BUILDING; <br /> <br />MAILING ADDRESS: SUBOIVISION'. <br /> <br />4-'166 CALSOh. DR SE <br /> <br />SALEM, OR 9?30] <br />PHONE-' <br /> <br />LOT: ' BLOC~i <br /> <br /> b~RTHi <br />102 <br /> <br /> SiTE NUI'CtiPER:92-01598 <br /> VALUA'T'iON: <br />BECTION~ TOWNSN IR: RANGE: ZONE: <br /> <br />AREA: UNITS: I~REG. LOT: CORNER; <br /> 11118. SF NO! NO <br /> <br />RES [ DEN ] [ Al_ <br /> <br />M~p; <br /> <br />TYPE: ON-SITE SENAGE <br /> <br />PERf~ T OR APPLICA'f'iON NO: 9039573 <br /> <br />CONTRAC/'OR, NO. 5358~ <br /> CANYON CONS'f'UCfJON <br />P O BOX 5? <br />5f'AY'fON, 9?383 <br />PHONE: '769-~584 <br /> <br />WATER SUPPLY: PW <br />'I'ES'f HOLES READY: <br />SiTE EVALUA'I'ION NUMBER: <br />EXiSTiNG TANK SIZE: <br />EXiSTiNG D'RAiN FIELD LINES: <br />SEPTIC TANK PU~PEO: <br />PREVIOUS NO. BEDROOMS: <br /> <br />SEEPAGE ~RENCH ~% '~ $2~0 00 <br /> <br />PAYEE: AOAIVI,5~ SALLEY <br /> <br />TOTAL A~E~EO ~EES $2~0,00 <br />PREVIOUS RECEIPTS $0,00 <br />'FHZS R~CEZP'f' $2]0-00 <br /> <br />BALANCE DUE $0.00 <br /> <br />INVOICE NO; 4!~22 <br /> <br /> REC'EIVE0 BY: CL TYPE; IN CHECK ~: 0 <br /> <br /> BEE ATTACHED 0OCUMENT FOR REQUIREMENI'~ OF ON-SITE SENA(~E SYSTEM. <br /> <br />~ THiS IS NOT A PERNIT. THiS APPLiCATiON NUST GO THROUGH A REViEH PROCESS ~ERE THE <br />FOLLC~/ING RUST /BE CO~IPLETED. IT IS THE RESPONSiBILiTY OF THE APPLICANT TO ~RE '[HAT <br />ALL NEC~RY INFOR/~IATiON HAS 8EI~J P~3VlOED. <br /> <br />OFFICE COPY <br /> <br /> <br />