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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO. 225 <br /> 220 HIGH STP~EET 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 SIGNATURE OF APPLICANT; ..................................... <br /> The work will be performed by a registered builder. I <br /> Other ' <br /> I have read and agree to the terms sta~ed on the reverse side of DATE; ........... ' ..................... <br /> <br /> SITE HU~iBER= 74-~11171 <br />' ' F'HONE.~ 682--7,~;69 VALUATION: <br /> <br />TYPE: lIN~SITE SEWAGE <br /> <br />PERHIT OR APPLICATION HO: <br /> <br />.C,,ONTRACTOR~ NO. 1~$75 <br />S~:a~iey M Keiqh'i:ley <br />;I3640 Oak Rd RW <br /> <br />PHONE: 868'-7388 <br /> <br />~8535&2 <br /> <br />WATER SUPPLY: CW <br />TEST HOLES READY: <br />SITE EVALUATION NUHBER: KABEL CT <br />EXISTING TANK SIZE: <br />EXISTIN(; DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BESROOMS: <br /> <br /> i'rEM QUANT I TY AMOUNT <br /> STANDARD ON=SITE SYSTEH 1 <br /> <br /> TOTAL,,ASSESSEIQ FEES $.~.~;~. 00 <br /> PREVIOUS RECEIPTS <br /> ~NI~ RECEIPT $255- <br /> <br /> BALANCE DUE $0. <br /> <br /> PAYEE: S~aoley H Keightley RECEiF'T NO: <br /> R(.CE1VEP BY: 01. TYPE: IN CHECK :~,: <br /> <br /> SEE ATTACHED ~OCUH~kT FOR ~E HENT.~ OF ON-SITE SEWAGE SYSTEM. <br /> <br /> ~ THIS I~ HOT A PEOHI,T. THI~APPE~CATIOH, HUST ~ THROUGH A REVIEW P~QCESS ~ERE THE <br />FOLLOW~'.NG .MUST ~E 6~PLETEO.. 'I~ ~S THE ,RESPONSIBILITY OP THE APPLICANT TO A~SURE THAT <br />ALL NECE,~GARY INFORhATION HAS BEEN PAOV]:DED. <br /> <br />~RFI~IAR(Sr, ST~9 SYSTEM <br /> <br />CITY JUOISDICTI:ON BY ....................... DAI'E ............................ <br /> <br />OFFICE COPY <br /> <br /> <br />