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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- 4:80 <br /> 24 HOURiCODE-A-PHONE: 588-7904 <br /> <br />I am performing work on ~ property I own or occupy. <br />I 8m 8, registered builder OR the authorized representative SIGNATURE OF APPLICANT: <br />of a registered builder, <br />The work will be performed by a registered builderJ <br />Other, ,, <br />~ have read and agree to the terms stated on the r~verse side of DATE; <br />this document. , <br /> <br />OWNSR; Dh'f E,~ <br /> <br /> 14614 KASEL CT NE <br />AiJRORA OR 97002 <br /> <br />CONSTRUCTION TYPE <br /> <br />O~)NTRACT CITY: JGEk <br />AURORA NO <br /> <br />:GAT~GORY; <br /> <br /> J~ESID ~h' 'ifA ~ <br />:OCCUPANCY~ <br /> <br /> :NO OF BEOR00M$ <br /> <br />TYPE: ON-SiTE SEWA§E <br /> <br />PERI, IT OR ~PPLigATISH NS: <br /> <br />~ONTRACTOR, 140. 1~S75 <br />S~:anIey M KeiqhtIey <br /> <br />Salem, 97~4--D~88 <br />PHONE: 868-7~88 <br /> <br />WATER SUPPLY: cw <br />TEST HOLES READY: <br />sz-rE EVALUATION NUMBER: KASEt. CT <br />EXISTING TANK SIZE: <br />EXISTING DRAIN ;IELD LIHES: <br />SEP'rIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> ITEM QUAN'¥'I TY AMOUNT <br /> STANDARD ON-SITE SYSTEM 1 <br /> <br /> TOTAL A~SE~SED FEES $255.08 <br /> PREVIOUS RECEIPTS $255,. <br /> THIS RECEIPT $e.~ <br /> <br /> BALANCE SUE ¢8., <br /> <br /> PAYEE: INVSICE <br /> RECEIVED BY: PB TYPE: CHECK ,~,: <br /> .................... % ~%%% % Z%% %%%%%~%Z~%5:~%:;~=~ .............................................................. <br /> SEE ATIACHED DOCUM(NT FOR REQplREMENTS OF ON-SITE SEWAGE <br /> <br />COHS'rRUC'rzo~ :Al S TO MEET ALL ~EQUtREMENTS OF STATE LAW~ AND MARION COUNTY BUlL. DING <br />70NIN60RDINANCES~ THIS PERMIT SHALL BECOME NULL AND VOID. <br /> <br />REMARKS: STD oYSIEM <br /> <br />BUILDING OFEICIA,'_ / BY <br /> <br />FORM # M:C 15.56 REV. 4/90 OF FiCE COPY <br /> <br /> <br />