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MARION COUNTY BUILDING iNSPECTION
<br />SENATOR BLDG. NO, 225
<br />220 HIGH STREET NE
<br /> SALEM1 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 ~ property I own or occupy.
<br />I am a registered builder OR ) the authorized representative
<br />of a registered builder.
<br />The work wHI be pedormed by a registered builder,
<br />Other
<br />~ have read and agree to the terms stated on the reverse side of
<br />this document.
<br />
<br />PI] BOX 412
<br />AtJRORA,~ OR 97{¢~12 ' SITE HUMBER: ~4-~404
<br />Fl.Ill.. ~?.t ~72J VALUATION:
<br />
<br />TYPE: [}N--SITE SEWAGE
<br />
<br />PERMIT SR APPLICATION
<br />
<br />[',Otq TI,'A C ]'('.IR, NIl. '
<br /> BO~'~ S ~ACKHOE
<br />1714~4 ~RBOR GROVE R~
<br />
<br />WATER SUPPLY: PW
<br />T[~:ST HOLES READY:
<br />SITE EYALUAT:I:ON NUMBER:
<br />EXiS'f'TN[; TANK SIZE:
<br />[-;X]ST):N~; DRAi',d FIELD LINES:
<br />SEPTIC TANK F;'UMF'ED:
<br />PREVIOUS N(],, E~ED2OOHSs
<br />
<br /> ); TE"H 01.5A N T I TY A['I 0 U N'f'
<br /> RLPAIR - M:FNCiR 1
<br />
<br /> TOTAL ASSE:SSE~ FEEB
<br /> PkE IOU. RE(.EIF, IS $85.,
<br /> ~ H.I. 5 RECEIF T
<br />
<br /> BALANCE DUE
<br />
<br /> ~ ~-.~.,. REL~:.IP7
<br /> I~ECE';I Vi.i> BY: (;~... .................................................................... TYF'E:
<br /> ,~F,h ATTACHE~ DOCUHENT FOR REQIITREMENTS OF' OIq."f',]Yf'E SEWAL,,:
<br /> --.,.....-..,....,.-,-.,- ................................... ~.~ .... -.~ .................... ~ ....................................... ~ ~.. ~,,. .........................................................
<br /> *~T~I~ !$ A ~D ~ERNIT $ THiS PERNIT EXPIRES ~8 DAYS FRSM ~TS ISSU~ DATE. IF
<br />CFH,,~,RUF, TfFH,~ F,~-!'.u_S f'O ~E~'F'¢f,,L ~EQU];RE~HZS OF STATE LA~S A,D ~AR Dq F ;],'fy ~{" l)F".;" ':
<br /> k ~; ~;~)~A,,E.H, 'f'qTS FF:F¢tT SHALL BEgOnE NULL AND VO,;D. '
<br />
<br /> .MC ~ ..... ].!] R.. TANK Ot%.Y
<br />
<br />'!')£1]'.hrf,.!:! ~,. .,,....,I i, ;'iA!,:iF~i,! ,&,,;~t, BL:!IDII,!~; I:!F'P:t:C:!Y,,',L, / BY
<br />
<br />OFFICE COPY
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