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Marion County ~ 1~ ~ ~ ~ <br /> 220 ~HIOH STREET NE <br /> OREGON ~ <br /> COMMUNITY DEVELOPMENT FEg 1 7 <br /> DEPARTMENT <br /> <br /> BUILDING <br /> <br />BUBSt/RFACE SEWAGE coMPLAINT FORM <br /> <br />Nature and location of Subsurface problem: Please describe in detail and show <br />location below. Be specific. <br /> <br />WEST <br /> <br />SITE ADDRESS: <br /> <br />PROPERTY OWNER: <br /> <br />EAST <br /> <br />SOUTH <br /> <br /> TAX LOT NUMBER: <br />Street <br /> <br /> ?? <br /> <br /> Address <br /> <br /> Add~ess <br /> <br />The name of any complainant will remain confidential unless requited by law to <br /> <br />Map: <br />Field Check By= <br />Letter: Date: <br />DEQ: Date: <br /> <br />MCi5-S6 <br />REV 12/92 <br /> <br />FOR OFFICE USE ONLY S-T-R: <br />Date: <br />Letter: Date: <br /> <br /> <br />