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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: S88-7904 <br /> <br />I am performing work on a property I own or occupy, <br />I atria registered builder OR( ) the authorized representative <br />of a registered builder. <br />The work will be performed by a regfstered builder. <br />Other. <br /> <br />SIGNATURE OF APPLICANT: <br /> DATE: <br /> <br />I CON~TRu~TION TYPE: <br /> <br /> :;-4&:t¢5 KASEL C'F -- <br />ALIRORA OR ~e~D2 I,, <br /> <br />PORI'I,,,AN~, OR 97219 SITE <br />PHONE: 244-6221 : VALUA'T]:ON: <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERNIT OR APPLICATION <br /> <br />Ii;ONTRACIOR~ NO. 19575 <br />SL'an:l. ey ~ I?ightley <br />1364~ Oak Rd EW <br />SaleM~ <br />PHONE: 868-7388 <br /> <br />9~53763 <br /> <br />WATER SUPPLY: CW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: 38743 <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES: <br />SEPTIC 'TANK PUMPED: <br />PREVIOUS NO. BEDROOM!~: <br /> <br /> :ITEM £~UANT ITY AMOUNT <br /> STANDARD ON-SiTE SYSTEM I $25%00 <br /> <br /> T0'CAI. ASSESSED FEEL $255. <br /> PREVIOUS RECEIPTS $~.. <br /> TH~S RECE~P'T ~255. <br /> <br /> BALANOE OWE <br /> <br /> PAYEE: Stanley ~ Keigh~ley ZNVO]:OE NO: 562'33 <br /> RE. LEIVED BY: PM .............................................. TYPE: IN CHECK ,~: <br /> <br /> SEE A'flAOHED DOOU~ENT FOR REDUIRE~ENT'S OF QN-SITE SEWAGE SYSTEM. <br /> <br />hOI. LO~ZN6 HUST ~E COHPLETE~. ~T ~S THE EESF'OHS~;[L, ZTY OF TWE ~PPLZC~T TO ~SSURE TUfT <br />ALL NECESSARY ~t4FORMATXO, HAS ~EEN PROVIDED, <br /> <br /> DY ....~,~ D~TE._,.~_~.~.__ CITY JSRI~DZCTION: ~Y ............................. D~TE ...................... <br /> <br />PLAN ~EV,I, EW,, <br />I:~EMARKS: St] <br /> <br />~ORM, ~C 1S-Se .Er. 4/eo OFFICE COPY <br /> <br /> <br />