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Other <br /> <br />this document, <br /> <br />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 /> SIGNATURE OF APPt. ICANT:DATE,. <br /> <br /> ] CONTRACT CITY'. <br />; J!465 MOCLELLAN LN SE; i , <br /> <br /> li4S6 MCCLELLAN LN SE · <br /> AUSVILLE,, OREGON ~7J25 I SITE HUHBER: <br /> PHQNE~ 7¢9-240_4 ~ J. VEL,J,~ST ~, gi~ ......... <br /> <br />!~ .................... ~,~. ~ ~.~.v~[ ................ .~_.¢~_~ .................... L___~T2 ............... L.~...:~3 <br /> <br />TYPE: OH-SITE SEWAGE <br /> <br />PERfiIT OR APPLICATION <br />COFITRACTO~ NO. ~6786.~/ <br />VAL. L. EY SEPTIC <br />P S BOX 5241 <br /> <br />785354& <br /> <br />WATER SUPPLY: F'W <br />TEST HOLES READY: NO <br />SITE EVALUATION NUMBER: <br />EXISTING TANK S%ZE: <br />EXISTIHG ~RAIN FIELD Li[NES: <br />SEPTIC TANK PUNF'ED: <br />PREVlOO8 NO., BEDROOMS: <br /> <br />ITE~I £~UANT I TY AMOUNT <br />REF'AIF~ - MAJOR 1 $12.5,,80 <br /> <br /> TOTAL-ASSESSE~ FEES <br />~i~%PRE¥2OUS R[GEIPTS <br /> TH'IS RECEIFT <br /> <br />$125.00 <br />$225.00 <br /> <br />BAt ANCE DUE $0.08 <br /> <br />PAYEE: VALLEY SEPTIC RECEIPT NO." 5¢~010 <br />RE(;EIVEI) BY: CL TYPE:: CK CHECK ~: 610 <br /> <br /> SEE ATTACHE~) DSOUMEIqT FOR REtlUIREMENTS OF ON-SITE gEWAGE SYSTEM. <br /> <br /> ~ THIS IS NOT A PERHIT. THIS APPEICATIOH HBST GO THOUGH A REVIEW PROCESS WHERE THE <br />F'OI...LOWING MUST ~E COMPLETED. I7 IS THE RESPONSIBILITY OF THE APPL. IBANT TO ASSURE THAT <br />ALL NECESSARY INFOR~fATION HAS BEEN P~OV[DE9. <br /> <br />RE~/ARES: SR: H,JR (E.f-AJF THtNO <br /> <br />CITY JURISDICTION: BY ............................ :OA'fE ................................. <br /> <br />FORM # Mc ~-56 REV. 4]9O <br /> <br />OFFICE COPY <br /> <br /> <br />