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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 /> <br />I am performing work on a property I own or occupy. <br />I am a registered builder OR the authorized representative ~f~NATURE OF AePLICANT'. <br />of a registered builder. <br />The work will be performed by a registered builder, <br />Other. <br />~ have read and agree to the terms stated on the reverse side of OATE: <br />this document. <br /> <br /> CONLEY~ Mil(I; ~ i RES:[DENT:[AL <br /> <br /> J, 0-°44 HILL CREEK RD SE CONTRACT CIT¥~ ( UGEI', IOOOUeAN¥ LOAD: <br /> AUHSVILLE OR ~7~25 HA~ION COUNTY ' NO ,; <br />;'OSE OF 8uILO¢~: : NO, OF BEDROOMS: <br /> <br /> 352 HONSON <br /> SII,.VERTOI'h~ OR 97;~81 ' SITE NUHBER: 74-~29111 <br /> PHONE: 87~-1199 VALUATION: <br /> <br />LOT'. i BLOOKJ i SECTION: <br /> <br />TYPE= ON-SITE SEWAGE <br /> <br />PERMIT OR APPL%CAT[ON <br /> <br />[;,ON I'RACTOR,. NO. <br />f,,ONLEY.~ .i 1% El'_'.: <br />;52 ~IONSON <br />~tLVERTON~ OR ~7381 <br />FI,lONE: 875-t199 <br /> <br />WATER SUPPLY: PW <br />TEST HOL, ES READY: <br />SITE EVALUATION NtJMBER: <br />EXISTING TANK SIZE: 1000 <br />EXISTING DRAIN FIELD LINES: <br />SEPIlC TANK PUIIPED~ <br />PRE¥IOUS NO. BEDROOIIS; <br /> <br /> ~TEii QUANTITY AHOIJNT <br /> AUTHORIZATION NOTICE - FLD. VISIT ~ $160.00 <br /> <br /> TOTAL ASSESSED FEES $160.00 <br /> PRE¥.OUS RECEIPIS $0.00 <br /> ~NIS RECEIPT <br /> <br /> BAbANCE ~UE' $0.88 <br /> PAYEE: MOI,.ES~ RAYMOND RECEIPT BIO: 5~5:I5 <br /> RECEIVED BY: PM .......................................... TYPE: OK CHECK ~: <br /> CREQU,I,REMEN~ OF,ON-SI~E ~EWAGE SYS1EM. <br /> · TH;S ZS NOT A ~ERHIT. ,THIS, APP~IC~ON'~UST ~O ~HROU~H.A REVIEW PROCESS ~ERE THE <br />FSI-,L~NIN~ HU~T ~E CSHPLETED, IT' ZS,,T,FE' RESPONSIDIJITY OF 'THE APPLICANT TO ASSURE THnT <br />AI.L NECESSARY ~FORMA'FIOb NAnkEEN PROVID'~D:. <br /> <br />F'I.AN RI..V].LW, <br />REMAI;~KS: <br /> <br />~o~ # MC ~s,se ~v. 4~ OFFICE COPY <br /> <br /> <br />