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r. ~ INSPECTION
<br />SENATOR BLDG. NO. 225
<br />';'20 HtGH STREET NF
<br /> " SALI::M, OREGON97~01 ~"I / L,.
<br /> PHONE: 588-5147 8:00 - 4:30 - ,~,,~_.
<br /> 24 HOUR CODE-A-PHONE: 588-7904 ~
<br /> lam performing work on a property I ow. or occupy· ,~.,..~.~ / ././ /~.~ 'Z
<br /> I am a registered builder OR the authorized representative SiG NATU R E Q F A P P LI~'/~¢~. ~.~' ~ ~' ~/
<br /> of a registered builder. // ..
<br /> The work will be p~rformed bY a registered builder. ] ~
<br />
<br /> t have reod 2ad ~9ree to the term8 stated on the reverse side of OAT2: ..~;~ ¢
<br /> fh~s docur~ent.
<br />
<br />[ht'~. ,: ,~ Wl ; RES];DENT:.AL
<br />
<br /> .......... 2
<br />
<br />kuL ~ 69/~-7954
<br />
<br />· SITE
<br />
<br />TYPE: OH-SITE SEWAGE
<br />
<br />PER,Il' OR APPLICATIOH HO:
<br />
<br />CC/I~'~RACTOJ%
<br />
<br />HATE]R GUF'F'L,Y:
<br />TEST HCJLED
<br />S].TE EYALUAT Zoi, i
<br />EX~STIHG TANK SIZE~
<br />EX];S'F].NG DRAJ[N F'~ELD LINES:
<br />SEPT~u T~NK F'U~F'ED~
<br />PF~E¥~OUS NO.
<br />
<br /> ]iTEM L~uAN"F l TY
<br />AU'Y}IOf;[l'Zh'l':f'Olq I,~OT,TCE -
<br />
<br />TOTAL ASSESSED FEES
<br />PF, nV,,.OU,~ R~Cb'rF , o
<br />
<br /> {E ...... ttYl,,,.:,,, .4 REQE:I:PT NO: 60.487
<br />.................... ,,-,. ........................................................................ -FY,r':'E; CK Cl'L.k ~,: 726?
<br /> Fc ¢t'F]C,C..I'IF.'J') )')dC ]f'lI';t,]] :'DR R~.,QU.EkEHENTS OF ON-S, ]
<br />
<br /> THIS IS NOT A PERI,lIT,, THIS APpL'tCATIDH MUST GO THROUGH A REVIEW PROC[SS WHERE THE
<br /> O~U],!E. Itl,;rST ~'dk'. !';OHF'LE:Tr:') ;['T t% 'lTl[ R~PONSZ[,gIL;[-i'Y OF' ';-HE APPI..]:CAN'T TO ~,ssdj:,'E 'lHf. Vi
<br /> ,.l..~ ..... /.,,I.Y .iM 0 dn..,i'.,.~ll Ith,., BFi:'N
<br />
<br />!:',! ./:~ H R'i:;V Jl Ekh:
<br />::d /'hf'r R I~;!!; ':
<br />
<br />I r I:ql:f;ED 'TO CALL tj:r.T 6¢o-79..
<br />
<br />~o~ ~ ~c ~-s~ ~v. ~/~ OF FICE COPY
<br />
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