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MARION COUNTY B~ILD'i'~G 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 /> <br /> ~ am performi~9 work on A property I own or occupy, <br /> I am a registered budder OR ( ) the authorized representative <br /> of a registered builder, <br /> The work will be performed by a registered budder <br /> Other <br /> I have read and agree to the terms stated on the reverse side of <br /> this document. <br /> <br /> DATE: 02/14/94 TIME: 16:2i:02 <br />ow~.: NICKS';' GERALDINE <br /> <br /> 977i BRG~INELL DR SE <br />AUMBVILLE OR 97525 <br /> <br />' MAILING <br /> <br />RCttR'.I~49:R' ~6~UN T Y <br /> <br />I1~1~" .... i ocCUPAN~ LOAD: c.~ <br /> <br />PHONE: <br /> <br />SITE NUHBER: 94-00649 <br />VALUATZON: <br /> <br />....... IYP~: oN-SI fE "~EWAGE <br /> PERHIT OR APPLICATION NO: <br /> <br /> CONTRACTOR, NO. 34916 <br /> STAYTON SEPTIC <br /> 41155 STAYTON SOlO DR SE <br /> $TAYTON, 97583 <br /> PHONE~ 769-.2302 <br /> <br />'"AREA 5'.' ' "~jI~I~C <br /> <br />RANGE'. '!' Z'~) N E: MAP: <br />i~ < AR ~ 48 <br /> <br />I~G, LOT <br /> <br />9052888 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY= <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br />ITEM QUANTITY AMOUNT <br />REPAIR ~ MAJOR <br /> <br /> TOTAL ASSESSED FEES $125.oo <br /> PREVIOUS RECEIPTS $0.00 <br /> ] THIS RECEIPT $125.00 <br /> ~ALANCE DUE $0.00 <br /> PAYEE: STAYTON SEPTIC <br /> RECEIYED BY: DM2. --=~.~ _~ TYPE: CK CHECK ~: 14570 <br /> SEE ATTACHED DOCUMENT FOR REQUIREMENT8 OF ON-SITE SEWAGE SYSTEM. <br /> m THIS IS NOT ~ PERHIT; THiS::,~PPLICRTION HUST: 60 THROUGH R REVIEe PROCESS WHERE THE <br />FOLLOWING MUST BE COMPLETEDZ IT IS THE REsPoNSIBILITY OF THE APPLICANT TO ASSURE THAT <br /> <br /> ALL NECESSRRY INFORMATION N~S BEEN PROVIDED. <br /> <br />REMARKS:~.~R RE~ TM:RE*DY 2/14/94 <br /> <br />FORM ~ Mc ~s-~s nEv. ~'~ OFFICE COPY <br /> <br /> <br />