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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO. 225 <br />.~ 220 HIGH STREET NE F I L E <br /> SALEM, OREGON 97301 <br /> <br /> : PHONE:::588,5147'r. 8:00 :. 4:30 .:~ <br /> · ' 24 HOUR' CODE-A;PHONE:' 588:7904 :'::: ' ~" :~:' ' <br /> <br /> I am a reglste~ed builder OR the authorized representative EtGNATURE OF APPLICANT' <br /> of a ag s ered bu der . , ...... ~ ,, - - ~ · . , <br /> The work w I be pedofmed by e. registered builder. .... ' ' , ' <br /> Other , " ,' : ' :'" ' ,:' ',:'~: ' :': ' <br /> I have read and agree ~o the terms stated on tl3e reverse side of DATE; <br /> this document, <br /> <br /> USSELMAN, S. & H. <br />.[~u~65~.' .................................................. <br /> <br /> UMSVtLLE HWY <br /> AUMSVILLE ~ <br /> <br />MAILING ADDRESS: <br /> <br />301S STARR CT NE <br />SALEM OR 97303 <br />PHONE= 588~039~ <br /> <br /> TAX LOT; j CATEGORY; <br /> 75~01-i~0 I RESIDENTIAL <br /> "-- C'"~ONSTRU--~TI'~N TYPE'· (~U~-~'~ <br /> <br /> SE' , ': ' : ~NT.AOT CITY: [UGt: OCCUPA~f'Eb~6~ <br />~732~ '.~' ,.,' MAR:IoN .COUNTY~NO <br /> .... , ...... . - ....... ~ ~2-~ ~.~-~: <br /> <br /> WALDO <br /> <br /> SITE HUMBER= 94-01912 <br /> VALUATION: <br /> <br />1.96§ AC YES NO <br /> <br />MAP: <br /> <br />TYPE= ON-SITE <br /> <br />CONTRACTOR. HO. <br />USSELMAN~ ~. & <br />~015 STARk CT NE <br />SALEM OR ~7303 <br />PHONE= <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY= YES <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LIHES= <br />SEPTIC TANK PUMPED= <br /> <br /> ITEN <br />SITE EVALUATION, EA. <br /> <br />PAYEE: NICOLL <br />RECEIVED BY: <br /> <br />SEE ATTACHED DOCUMENT <br /> <br />QUANTITY AMOUNT <br /> 1 $.~25.~0 <br /> <br />$22%,00 <br /> $0.00 <br />$225.00 <br /> <br /> RECEIPT NO: 57505 <br /> TYPE: CK CHECK ~: 2445 <br /> <br />~YSTEM. <br /> <br />$0.00 <br /> <br /> MOl'E: THIS DOES blOT ti, <br />ON,~TRUCTION PERMITS <br /> <br /> PI. AH REVIEW: <br /> <br /> REMARKS: SS: SE: TH: READY~M. tNOR ~,CRTI17t, ON <br /> <br />IN~THIS PARCEL. PLANNING AND <br />~I:,PTIC INSTALLATION BEGINS, <br /> <br />ICTION: BY ............ DATE ..................... <br /> <br />1 # MC ~ 5.5(i RE"V, 4,~90 OFFICE coPY <br /> <br /> <br />