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MARION COUNTY BUILDING INSPECTION <br />SENATOF~ BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 9'7301 <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 oooupy, <br />I am a registered b~ilder OR the authorized representative <br /> of a (eglstered builder, <br />The work will be performed by a registered builder. <br />Other ............ <br />I have read and agree to the terms stated on the reverse side of <br />this document. <br /> <br />SIGNATURE Or APPLICANT~ <br /> DATE'. <br /> <br />, owr~ER:DATE~~ 'f~771479~ .... TI FfE-:' ' -I J f'0'7~'2;~ !' TXX' LOTi ~ C~f~aO~V: <br /> <br /> 122~5 WEST SFAY'fON RD SE , ~ <br /> AUHSVILLE ~E.._ ~Z~ <br /> <br />' SITE NU~ER: 94-~2~91 <br /> PHONI:,, 769-~4L VALUATION: <br /> <br />TYPE: OH-SITE SEWAGE <br /> <br />PER~I~'T OR APPLICATIOH <br />C(]NTR~CTOR~ NO. <br />WOOSI_EY:, ALt.,"~N A KAY <br /> <br />PHONE: <br /> <br />558?2 <br /> <br />WATER SUPPLY: <br />TEST HOLES READY. <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING ~RAIN FIELD LINES: <br />SEPTIC TANK PUMPE~: <br />PREVIOUS NO, BEDROOMS: 2 <br /> <br /> ITEM QUANTITY AHOUNT <br />AOTHORIZATION NOTICE - FL.B,, ¥ISI'f 1 $1,60.00 <br /> <br />TOTAL ASSESSED FEES <br />PREVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />BALANCE DUE <br /> <br />$160,00 <br />$].60.00 <br /> ~0.00 <br /> <br />$0.00 <br /> <br /> PAYEE: RECEIPT NO: <br /> RECEIVED BY: PB TYPE: CHECK ~: 0 <br /> oL'E A~TACHED DOCUMENT FOR ~EQUIREMENTS OP ON-~I1-E SEWAGE ~YSTE~. <br /> <br />" '. " ~ ~ T I. PER/4%T SHALL BECOME NULL 'AN~) VOID. ''" <br /> <br />REMARKS~ AUTH <br />DONALD E. WOODLF_'Y,~ HARION' COUNTY BUILDING 'OFFICIAI~ / BY <br /> <br />OPFICE COPY <br /> <br /> <br />