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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 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 /> I have read and agree to the terms 8tared on the reverse side of <br /> this document. <br /> <br /> DATE: 12/~0/91 f' i~4E ~ <br />: OWNER; <br /> COAKLE"(, ROONEY & MARIA <br /> <br /> SITUS ADDRESS: <br /> <br />SIGNATUR~ O~- APPLICANT: <br /> DATE: <br /> <br />TAX LOT; <br /> <br />56055~000 <br /> <br />CATEGORY; <br /> <br />OCCUPANCY: <br /> <br />RE~IDENJ[.AL <br /> <br /> 5'785 ~,HAW HHY <br />i AUIv~V;( LLE DR 9'7325 <br /> <br />coNTRACT CITY: ' UGB: <br />MARION COUNTY L NO <br /> <br />~AILING ADDRESS: ~ <br /> <br />PHONE: 581-1872 Si, 'TE NUIVlaER: 3193 <br /> VALUA'¥ iON: <br /> <br /> 4.9 AC . NO i NO <br /> <br />'TYPE: ON-SITE SEWAGE <br /> <br />PERMiI DR APPLiCATiON NOt <br /> <br />CONTRACTOR, NO. <br />COAKLEY, RODNEY ~ MARIA <br /> <br />PHONEt 581-q872 <br /> <br />90378?0 <br /> <br />WA'1'~R ~UPPL¥: PW <br />'f'~'f' HOLE~ READY: <br />SITE EVALLIA!'ION NUMBER: <br />F_~IST~NG 'lANK S~ZE: <br />EX~'f'ING DRAIN FIELD LINES: <br />SEP'['~C 'lANK PUMPED; 4-11-88 <br />PREVIOUS NO. BEOROO~t <br /> <br /> ~'~ PREVIOUS REG~iP'I'S $0.00 <br /> $0_ 09 <br /> <br />PAYEE: RECEiP'¥' NO: <br />RECEIVED BY: CL TYPE; C~ECK ~: 0 <br /> <br /> $~E A'I"f'ACHED D¢~UM~'f FOR REQUiREM~.N'rs OF ON-SITE ~E~AGESYS'FEM. <br /> <br />~ THiS ~S NOT A PEI;~lZT. TH~S APPLiCATiON NMST GO THROU~-I A REV~IEN PROCESS WHERE THE <br />FOLLOWING f, IUST BE CO~I~LETED. iT ZSTHE RESPONSiBiLiTY OF THE APPLZCANT TO ,¢~SSURE THAT <br />ALL NEC~x~ARY iNF-OR~lkTION HAS BEIEN PRC~IDED. <br /> <br />PLAN REVIEW: BY ................................. DATE ............................................ CiTY JURJSDiC'f'iON: BY ............................DA'IE <br /> <br />IkEMARK~: HD~P RENEWAL (PLANNING W~LL CREB!T PEP'f) ' <br /> <br /> OFFICE COPY <br />FORM # MC 15-56 REV, ,POO <br /> <br /> <br />