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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 />( ) Other .... <br /> <br />~UflOVILI,.E OR ~73,..,~ ~ M~R~ON COUNTY; NO , <br /> <br /> SITE HU~ER: ~172 <br /> NONE, VAL. UATION: <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION <br /> <br />CON'I'RACTOR~ MO. <br /> STAYTOM SKF'TIC <br />4:[;L55 STAYTON 8CIO DR <br />STAYTSN. <br />PHONE: 769--2~2 <br /> <br />WATER SUPPLY: F'W <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br />EXI~'fING TANK SIZE: <br />EXIS?ING DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS~ <br /> <br />ITEM QUANTITY AMOUNT <br />REPAIR - MAJOR 1 $125.00 <br /> <br />TOTAL ASSESSE~ FEES <br /> I~ub RECEIFTS <br />TNI~: REOEIPI <br /> <br />!~125.08 <br /> $(4.0(4 <br />$1~5,, 0(4 <br /> <br />BALANCE, BUR $(4,. 0(4 <br /> <br /> PAYEE: STAYTON SEPTIC RECEIPT NO: 52288 <br /> RECE%VF.'.D BY: CL TYPE: 6K CHFCK ~: 14288 <br /> SEE ATTACHED DOCUMENT FOR REQUIREMENTS OF." ON-CITE SEWAGE SYSTEM. <br /> <br /> * THIS IS NOT A PERMIT. THIS APPLICATION MUST ~ THROUGH A REVIEW PROCESS WHERE THE <br />FO[.LOW]]NI; MU~T 8E COMPLETED. IT lB THE RESPONSIBILITY OF THE APPLICANT TO AS~gF(E THAT <br />ALL. NECESSARY INFORMATION HAS BEEN PROVIDED. <br /> <br />PLAM RE.V,£EW. 8Y DATE <br />REMARKG: TH: 9.-,15-9.S <br /> <br />CITY JURISDIC'rloH: DY .............. DATE .......................... <br /> <br />ID- <br /> <br />OFFICE COPY <br /> <br />FORM # MC 1 S-56 REV, 4/9O <br /> <br /> <br />