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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, ORr=GON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />of a registered builder, <br /> <br />Other <br /> <br />have read and agree to the terms stated on the reverse side of <br /> <br />SIGNATURE O¢ APPLIOAN'~ .~ <br /> <br />5~TN~R? '~'~t~-;~ ' ~r5-/-~',~./47~ .... ~r'~'E'~ ~5~'4~- ' TAX LOT ..................... ~ CATEGORY; <br /> <br />.......... fZ_[l.l_Jd&~ .J~E.~ ..&.~O.~l~.h ........................................... RE~Z~EN't't~L <br />~ITU~ ADDRE$~'. CONSTRUCTION TYPE~ OCCUPANCY'. <br /> I <br /> <br /> 7728 SHERMAN RD SE CONCR~T~I~': .........["~'. '~OCCUPANT <br /> AUMSVILLE '" OR ?7325 ' LMARION COUNTY~ NO <br />u'~-~ '0¢ ~uiEoiW'e'; ............................................................................................................ ~ ,~ <br /> <br />MAILING ADORE~9. SUBDIVISION: <br /> <br /> CONTACT: 769-2302 SITE NUNBER.' 74-B2157 <br /> PHONE: VALUATION: <br />~-T .............. ' 'I~,Z6~F ............... -'f~,~+i6~---~ .......... -[~RT~- .............. ¢'~N~'~ ............... 1"~8~,; .............. ~ '~P' <br /> ..... ........ ..... .... ........ ............ <br />...... _1 . J I ............. J____u~ ................. L.._~ .................... ~ <br /> <br />TYPE: ON-SITE SEWAGE WATER SUPPLY: PW <br /> TEST HOLES READY: <br />PERMIT OR APPLICATION floc ?055441 SITE EVALUATION NUHBER: <br /> EXISTING TANK SIZE: 1588 <br />C~NTRACTOR~ NO. 54916 EXISTING DRAIN FIELD LINES: <br />STAYTQN SEPTIC ......... SEPTIC ~AN,K;,PUMPED: <br />41155 STAYTON SC~O ~R~'S£ ' ' ['PREVIOUS NO. <br /> <br /> i ~EH :, ' QUANTITY AMOUNT <br /> <br />EXISTING SYSTEH EVAL. <br /> <br /> PAYEE: $1AYTON <br /> RECEIVED BY: PH <br /> <br /> SEE ATTACHE]) I)OCUHENT <br /> <br /> $ THIS IS NOT ~ PERHI <br />FOLLOWING HUST' BI": COHPL <br />ALI_ NECESSARY INFORMATI <br /> <br />FEES $I6~],, 68 <br />'TS $0,, BO <br /> <br /> $0.00 <br /> <br /> RECEI'PT NO: 57909 <br /> TYPE= CK CHECK ~ ~4~78 <br /> <br /> A REVIE~ PROCESS WHERE THE <br /> APPLICANT TO ASSURE THA'T <br /> <br />BY ................... DATE ......................... <br /> <br />OFFICE COPY <br /> <br /> <br />