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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM1 OREGON 97301 <br /> <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am performing work on a property I owr~ or occupy. <br />I am a registered builder OR the authorized representative SIGNATUR~ 0¢ APPLICANT: <br /> <br />The work will be pedermed by a registel'ed bui,der. <br /> <br />9176 BATES Pr)A)) SE: j CONTRACT Ci~Y: ~ U~S; ; OCCUPANT LOAD: <br />~USE OF BUILDINg'. tHO OF BEDROOMS: <br />'~iL,~'&6~s; ....................................................... f '&~'B~ia~; ..................... <br /> <br />YALUA~ <br /> <br />PERMTT OR APPLICATION NO... <br /> <br />Df-f'( F'HONF: : CHAD 74 <br />PHONE: 749--1~26 <br /> <br />9057985 <br /> <br />WA?t.:R SUPPLY: Pg <br />TEST HOLES READY: <br />SITE EVALUATION N[JMBE~: <br />EXiSTIN~ 'TANI~ SIZE: <br />FXISTINg DRAIN ';'IEL) LiNES,~ <br />SEP]'~C TANK F'UMPED~ <br />PREVIOUS ~0,, ~EDROOMS~ 2 <br /> <br /> f T,:.II ~]UAhI'f'I TY AW ~ i'~ ~' <br />A~P,'HOR)'ZAT:f:ON HOP], ,~ -- FI,;D,, V.~$I: :l $,r, 6" r, ......... ..., <br /> <br /> TOTAL A~SES ~.;]:) <br /> <br />, AfLE,,,, ¢ ..- ,'."nl'"~A~'H*~ . CORiE & ,. ',AD <br />R~.,'[;.F~I.D ,.Y. ~ ............................................................. ]YF'E~J 5K CH;;L,~ :~i,~ 889 <br /> <br />~;L'.F. ATIA HFD POCUME'N'F FOR kEi~WIREMENTc, OF ON-~Z'i'E SEWAGE SYSTEM,, <br /> <br /> THIS lB NOT A PERMIT., THIS APPLICATION: MUST GO THROU6H A REVIEW PROCESS WHERE THE <br /> 1.f .Ia THE ,~ESPONo..BZL,[TY 0~' THE APPLICANT TO A..U ~.. T .~A'!- <br /> LI.CL,,AI , c. p. , .. <br /> <br />FORM # M~ 15-56 REV. 4/90 OF FICE COPY <br /> <br /> <br />