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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 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> I am performing work on a property I own or occupy. <br /> I am a registered builder OR the authorized representative <br /> of a registered builder. <br /> ¥1~e work will be gerformed by a registered builder, <br /> Other ..... <br /> I hsve read and agree to the terms stated on the reverse side of <br /> this document. <br /> <br />DA'rE: 12/~1/94 TIME: 10=8~:09 <br /> <br />iI OWN" F~ A k ~.~ Aii~: g ~ !i: ~]~E T ..... iTAX LOT; <br />: SITUS ADD~ES~: ] CONSTRUCTION TYPE'. ] OCCUPANCY: <br /> <br /> 9393 PORTER RD <br /> ~-~0¢ 6CCU~AN~ <br /> AUMSVILLE OR 97S25 f~N~ ~i~~'' LOAD, <br /> <br />OF 8EOAOOMS: <br /> <br />SAME <br /> SITE NUMBER: 94-84515 <br />PHONE: 749-2643 VALUATION: <br /> <br /> ', ~S, 12W I EEU :62 <br />, <br />IWIDTH: IDE PT H'. ! AREA; <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION NO: <br /> <br />C0MTR~r, fOR. i,io. <br />WALI..ACE,~ MINNET <br />SAME <br /> <br />PHONE~ 749--2¢,4;t <br /> <br />9859963 <br /> <br />WATER SUPPLY:: <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br />EX)STING TANK SIZE: <br />EXISTING ~RAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />p~E~!OUSMO. BEDROOMS: <br /> <br /> ITEM QUANTITY AMOUNT <br /> ANMUAL EVAL - TEMP OR HQSHP MH 1 $90.00 <br /> <br /> TOTAL ASSESSEB FEES $90.00 <br /> PREVIOUS RECEIPTS $90.00 <br /> THIS RECEIPT $0.00 <br /> <br /> BALANCE ~UE $0,,~0 <br /> PAYEE:: RF~FTPT <br /> <br /> ........................ ============================== ............... ~_..,,,..~ ......... ~ .................... <br /> SEE ATTACHED DOCUMENT FOR REQUIREMENTS DF ON-SITE SEWAGE SYSTEM, <br /> <br /> ~ TNIS IS ~OT A PERMIT, ~HIS APPLIC~TIQN.M~gT ~ TBRBO6~ A REVIEW PROGESS WHERE THE <br />FOLLOWING MUST BE COMPt_ETED. IT' IS THE RESPQNSIBILITY OF THE APPLICANT TO ASSURE THAT <br />ALL NECESSARY INFORMATION NAS BEEN PRO¥I~EB. <br /> <br />DATE; <br /> <br /> OFFICE COPY <br />FORM # MC 18-~6 REV. 4¢3o <br /> <br /> <br />