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/4,,0~ '?STH t ~,AI.,,_, <br />(,,flJFtEW Z I, l, <br /> <br />.... MARION COUNTY BUILDING INSPECTION <br /> ~ SENATOR BLDG. NO. 225 <br /> 220 ~H STREET 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 perfo~ing work on a property I own or occupy, <br /> t am ~ registered builder OR the authorized represen 8 ire S GNA"UHE OF APPL CA <br /> <br /> The WOrk will be performed by a registered builder, <br /> Other_ <br /> <br /> l)h't'k3= 06124194 'r J. NE: <br /> <br />0 R <br /> <br />CONSTRUCTION TYPE: OCCUPANCY: <br /> <br />]':' 0 J. UX ? <br />ALI~t,SV Z LJ. J:'. ,~ <br /> <br />r SF. CTION: .... 'f6~][:;; .......... RA~6: J Z6N~: , MAP: <br />26 : 8S 2W EF'U 51 <br /> <br />TYPE: ON-S.I~TE SEWAGE <br />PER~IT OR ~PPLIDATION NO; 9056B92 <br /> <br />L[.]H iRAC,~01'G N(], ~6949 <br /> AAA SEPTIC ~"~"~' ' .... <br />PO BOX 2B811 <br />~ALEH~ ?730'7 <br />F I'K~NE= 378-"7454 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY,~ YE8 <br />SITE EVALUATION NUMBER: <br />EXISTING 'FANE <br />EXISTING DRAIN FIELD <br />SEPTIC TANK F'U~F'ED: <br />PRILiVIOU~ NO. BEDROONS;~ <br /> <br /> t'[EH QWANTI'FY AI~SUNT <br />$,ITE EVA/.UAT:[ON~ F'IRST: LOT :l. $26,5. <br /> <br />,M:.£.E 1 VED BY,~ <br /> <br />SEE A'TTACI,.IE]~) lr)0CIIMEI~]T F'OI~ RE~IUIR[ <br /> <br />ITOTAL ASSESSED FEES <br /> PREVI OU.~ RECEIPTS <br />THIS RECEIPT <br /> <br />$265.00 <br />~l~265., 00 <br /> <br />BALANCE DUE $(~,, 00 <br /> <br /> RECEIF'T NO: <br />TYPE: CHIECK ~: 0 <br /> <br />lENTS OE ON-SITE SEWAGE ,.IY,~ fE~,, <br /> <br /> HOTE:i 'TFU. D DOES NOT I;[(AI,IT OR "~'0 ' ~ ....... , F' ' <br /> IMFL, Y PERHXSSI. QI,! BUILD ON THIS ~AR[2::.L. <br />bH ),dJb],I, ON F'ERM:fTS MUST BC OBTAINED BEFORE BUILDIN~ OR SrJ~Z, ZNolAL,..AllON ~. ,. <br /> <br /> Pi,,AN REV:[EW~ BY ........................... DAT~ ........................... CITY JURISDICTION: BY .................... ])ATE <br /> <br /> OFFICE COPY <br />FORM # MC t ~-56 R£V. 4/9o <br /> <br /> <br />