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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 22S <br />220 HiGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:80 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> ,~ANE, <br /> PI4ONE: 749-1,35~ <br />LOT.' ............... i BLOCE~ ;SEC~ ON <br />iWIDTH: DEPTH; AREA'. <br /> <br /> PER~iT OR APPLICATION HO: <br /> <br /> CON'I RAC] OF<~ NO. <br /> MIX, F'RANCIS A. <br /> sA~,' / <br /> <br />PHOHE: 749-1354 <br /> <br /> ITEM <br />ANNUAL EVAL. - TEttF' <br /> <br /> S <br />20. AC <br /> <br />PAYEE'.' PLANNIHi <br />RECEIVED BY: <br /> <br />SEE A'FI'ACHEI <br /> <br /> * THIS IS <br />:OU,.OW [Fl(; <br />ALL <br /> <br />TI:AL <br /> <br /> NUMBER: 94-84897 <br />i VAI,.UATI ON: <br /> <br /> ¢ 1W ~ EFO <br /> ',NO ', NO <br /> <br />WATER SUPF'LY <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER:: <br />EX~STING TANK SIZE: <br />EXISTING DRAIN FIELI) LINES: <br />SEPTIC TANK PUMPEg: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> TOTAL ASSESSED FEES <br /> PREVIOUS RECEIPTS <br /> THIS RECEIF'T <br /> <br /> BALANCE DUE <br /> <br />TRAMS <br /> <br /> QUANTITY <br /> 1 <br /> <br /> RECE]:PT NO: <br />TYPE: IN CHECK <br /> <br /> )O[;UHENT FOR REQI IKE. MENIS OF ON-SITE SEWAf;E SY~IEM., <br /> <br />A PERMIT. THIS APPL,ICATION HU~T CO THROUGH A REVIEW PROCESS <br />EE COHFLEIED. , ~'r :Is THE RESPONSIBILITY OF THE APF'LICANT TO A <br />INFORMAl'ION HAS BEEN PROVIDE~,, <br /> <br />AMOUNT <br /> $90.00 <br /> <br /> $0,,00 <br /> $90.00 <br /> <br /> $0.00 <br /> <br /> 0 <br /> <br />RE THE <br />RE TNAT <br /> <br />BY ...............DATE .................... <br /> <br />RIF./HDSI;:' PF: NO LETTER NA]:L.,EJ~ <br /> <br />CITY JURISDICTION: BY ...................... <br /> <br />TE <br /> <br /> OFFICE COPY <br />FORM # MC 15.56 REV. 4190 <br /> <br /> <br />