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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG, NO. 225 <br />~ ~,!~1~,.. %, 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 /> I am performing work on a property I own or occupy, <br /> I ~m a registered builder OR the ~uthorized representative SIGNATURE OF APPLICANT:~ <br /> of a registered builder, <br /> <br /> this document, ~ ~ ~ <br /> I(EUDELL~ LARRY RESIDENTIAL <br /> <br /> 84~8 SILVER FALLS HWY SE 85~T~C~OITY: ~ocsuPANT LOAD: <br /> AUMSVIL[..E OR ~7~25 ~ARION COUNTY 'tNO <br /> <br /> : <br /> <br /> 1575 CAMBRIDGE DR SE <br /> SALEM~ OR ~7~2 ~T~ NUMB~: <br /> PHONE: 588-5724 <br /> ~ VALUATION: <br /> <br />.................... ; ................. ' .............. ................ <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERHIT OR APPLICATION <br /> <br />CONTRACTOR, NO. 36786 <br />VALLEY SEPTIC <br />P 0 BOX 5241 <br />SALEN~ 97384 <br />PHONE: 588-1115 <br /> <br />9858877 <br /> <br /> WATER'SUPPLY: PW <br /> TEST HOLES REABY: <br /> SITE EVALUATION NUMBER: 54487 <br /> EXISTING TANK SIZE: <br /> EXISTING DRAIN FIELD LINES: <br /> SEPTIC TANK PUMPED: <br />' PREVIOUS NO, BEDROOMS: <br /> <br /> TTEFI ~RC),.-~ QUANTITY Ai'.tOUNT <br /> STANBARD ON-SITE SYSTEM 1 $2§5.00 <br /> '~,,.~--~' TOTAL ASSESSE~ FEES <br /> PREVIOUS RECEIPTS <br /> THIS RECEIPT <br /> <br /> BALANCE ~UE <br /> <br /> PAYEE: LARRY KEUDELL RECEIPT NO: 61446 <br /> RECEIVEg BY: MB .................................... TYPE: CK CHECK ~: 1945 <br /> SEE ATTACHE~ gOCUMENT FOR REQUIREMENTS OF ON-S~TE SEWAGE SYSTEM. <br /> <br /> * THIS IS NOT A PERmiT. THIS ~PLICATIOH ~UST ~ THROUGH A REVIEW PROCESS WHERE THE <br />FOLLOWING MUST BE COMPLETES, IT ~S THE .REoPONSIBILITY OF THE APPLICANT TO ASoUBE THAT <br />ALL NECESSARY INFORMATION HAS BEEN pROVIBEQ, . <br /> <br /> OFF~CE COPY <br />FORM # MS 16-66 REV, <br /> <br /> <br />