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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:$0 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> The work will be performed by a re¢Jlsfered builder. <br /> Other <br /> <br /> tAlE., 06/24174 T:H'IE'.' 1,%¥4.4.¢ <br /> <br />ABDRESS: CONSTRUCTION TYPE' OCCUPANC~ <br /> <br /> 52e BANTIAM HWY N-' <br /> GATES OR ~7~4& ~I~cm C~TY N~a: ~CCUPA~r LOA~'. <br /> <br />MAILING ADDRESS: SUBDIVISION: <br /> S~ALL <br /> 884 WOODLAND ~R <br /> ~II.v!rR'r0N~ O,R. ~7;s81 SITE NUMBER: <br /> F NONI;: 872,--424~ VALUATION: <br /> <br />TYPE: OH-SITE SE~A~E <br /> <br />PERMTT OR APPLICATION <br /> <br />[;ONII.(AI. (Ok,, l lO,, <br />RO'I'H,¢ ORVIELE <br />884 WOODI.AN15 <br />S.[L, WERTOI% Ok ~?~81. <br />PHONE: <br /> <br />WATER SUPF'L.Y: CW <br />TEST HOLES READY,',' <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN F:I:IFL~) LINES: <br />SEPTIC TANK PUMF'E]): <br />PREVIOUS NO. BE:DROONS: 2 <br /> <br />AUTHORIZArION iq]T'O",E -. Ft..D. <br /> <br />PAYEE: RO'~'H~ UIWILL, E <br />R£OEIVED ~SY: PM <br /> <br /> QLIANT I TY <br />VISIT .1. <br /> <br />TOIAL A~SESSEI) FEES <br />PREVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />I)A'LANCE DUE <br /> <br /> S~;J':: ATTACHJ,~]I) DOrJUMEN'~ FOR ~E[,IUI-REMENTB ',,OF" ON~S~TE S~WAGE ~YSTEM. <br /> * THIS IS ~OT A ~ERfllT. THIS APPL[CATIOfl MUST GO THROOGH A REVIEW PROCESS WHERE THE <br />J';Ot [..Oiit].J,J~; HU~'~ ~ COWPLETIEI).' l'l' IS ]HE RESPONSIBILITY OF THE APPLICANT TO ASSURE <br />ALL N,r.,.ES. A[~ ( IN)':'O]~MAT:I;ON HAB BEEN <br /> <br />FORM If MC 15-56 REV, 4/90 <br /> <br />INVOIOE NO: 58582 <br />TYF'E: IN CHECK ~:: 0 <br /> <br />PLAN RFV'F'W: bY <br /> CITY JUNISD.[GII[N,~ BY ...................... DA'¥'I:i: <br />I~ :MA,~.\.~,, . c ,, <br /> <br /> <br />