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BUILDING <br />~"--~ NTY INSPECTION <br /> <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4;30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> Nf_ <br />97002 <br /> <br />GNATURE OF APPL CANT. <br /> <br /> DATE' <br /> <br />TAX LOT <br /> <br />OONSTRUCTfON TYPE' <br /> <br />USE OF ~UILDIN__~i:' <br /> <br /> OCCUPANCY: <br /> <br />: OOOUPANT LOAD: <br /> <br />MAIL, lNG ADDRESS; <br /> <br />2575 S!') FAI_.];..~AI),:.S I,,~;E,~f DR <br />I.AKF; OSW'F_'(;-[h, OR ~7035 <br />Ii"'N ON E: ~'~38'-g881 <br /> <br />SUBDI1, SION <br /> <br /> SITE NUM~E~: 94~e77~ <br /> VALUATION: <br /> <br />LOT. BLOCK; SECTION ..................... TOWNSHIP RANGE. , zONE' <br /> 11 4S I W P <br />WIOTA; 'DEPTH: ....... AREA: 26. UNi~ I ~?~ G. LOT O~.r~d S R: <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERHIT OR APPLICATION NO: <br /> <br />CCINTRAC, I'OR~ hi{:). <br />HOGAI'L, ,JACK <br />2::?3 SW FAI I,'-ADLS CREST DR <br />LAKt-~ O~W~r:GO. OR 97~Z5 <br />PI-lONE: 6Z8-8881 <br /> <br />MAP; <br /> <br />WATER SUPPLY: F'W <br />TEST HOLES READY: ~-:1,-94 <br />SITE; EVALUATION NUMBER:: <br />£XISTIN~ TANK SIZE: <br />EXISTING ORA:IN FIELD LINES: <br />SEPTIC TANK PUHPED: <br />PREVIOUS NO, 3EDROOHS:~ <br /> <br /> ITEM CUAN'fITY AMOUNT <br /> SITE EVALLIATICll4.¢ FIRST LOT ;i :; 2! 6 ,'.:: ,, 8('~ <br /> <br /> 'TOTAL AS.~ESSI;~ FEES ~I;265,, <br /> PREVIOUS RECEIPTS <br /> THIS RECEIPT <br /> <br /> BALANCE DUE <br /> <br /> PAYEE: RECEIPT NO: <br /> RECEI. VE~~ BY: PB .................................................... ~__._ TYPE: CHE{:,'( ~', <br /> <br /> ~EE AT~ACHED DO~UHEi,IT FOR REgUIR'E~ENTS~OF ON-SITE SEWAGE 8YSTEH. <br /> <br /> ~ THIS IS h VALI~ PERFllT · THIS PERmiT EXPIRES 36~ ~AYS FROfl ITS ISSUE DATE. <br />CONSTRUCTION FA.(LS TO HEET AEL REQUIREHENTS OF STATE LAWS AND ~ARZON COUNTY BU;f;LD1NG AND <br />Z(:)NIN~ OR~INA4[,I:S,¢ THIS PERMIT SHALL BE{,OHE NULL AND VOID,, <br /> <br />i¢ ,.,h AI,J~.,u.. <br /> <br /> MA,,,].t.~ CriUNTY ;~;{[J]]J:)IN~ OFI::'ICIAL / ~.4¥ .............................................................. .,~__,~. <br />I)ONAI.cD ~:,. W[!ODLJZY,~ ""'~ . <br /> <br /> OFFICE COPY <br />FORM # MC 15-5~ REV, 4/90 <br /> <br /> <br />