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'i, <br /> <br />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 />lam pe o mrlgwo kona propertylown or occupy. <br />I am a registered builder OR ( ) the Authorized representative <br />of a registered builder, <br />The work will be performed by a registered builder, <br />Other , <br /> <br />DATE: <br /> <br /> 1.,,1.¢., FRY RD NE , m <br /> OR_._..~_Z~ B~ ........... ~.¢~: ~ <br /> <br />PO ~SX 412 <br />PHONE: 878-5878 VAI._UAT ~ON: <br /> <br /> : <br /> <br />TYPE: OW-SITE SEWAGE <br /> <br />PERHIT OR APPLICATION NO: <br /> <br />COI,ITRACTOR, <br />NOWARD~ JORN & JEAN <br />PO BOX <br /> ORORA,, ?002 <br />F NONI-Z: 678-0870 <br /> <br />984~927 <br /> <br /> WATER SUPPLY. PW <br /> TEST HOLIES READY: <br /> SIT~ t~VALUATION NUNBER: <br /> EXISTING TANK SIZE: <br /> EX~STING DRAIN FIELD LINES: <br />: ~PT~ TANK PUMPED: <br /> PREVZ00S NO. BEDROOMS: <br /> <br /> ITEH QtJANTITY AMOUNT <br />AUTHORIZATION NOTICE - FL, D,, VISIT 1 <br /> <br /> TOTAL ASSESSED FEES $1~',o,, <br /> PREVIOUS RECEIPTS IB,, 00 <br /> THIS RECEIPT $].&g,, 0(8 <br /> <br /> BALANCE DUE $0. <br /> <br /> PAYEE~ HOWAR~ JOHN & JEAN RECEIPT NO: <br /> RECEIVED BY: F'M 'TYPE: CK CNI:,Ck <br /> <br /> SEE ATTACHED DOCUMENT PSR REQUZREHENTS OF ON-SITE SEWA[;E SYSTEM. <br /> <br /> ~ THIS IS NOT A PERNIT. THIS APPLICATION HUST 60 THROUGH A REVIEW PROCESS WHERE THE <br />FOLLOWING HLIST BE COMPLETED,. IT ISTHE RESPONSI(SILITY OF THE: APPLICANT TO ASSUI;LE THAT <br />ALL NECI:.,SARY ):NFBR~ATION HAS BEEN PROVIDED. <br /> <br />REHARKS: AUTH <br /> <br />CiTY JtJRISDICTIONi: <br /> <br />BY .......................... DATE ................................. <br /> <br />FORM # MC 15-~ R~, '4,~0 OFFICE COPY <br /> <br /> <br />