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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 progert¥ I own or oooupy. <br /> I 8m a registered builder OR ( ) the authorized representative SIGNATURE OF APPLICANT:, <br /> of a registered builder, <br /> The work WIH be pedormed by a registered builder. <br /> Other_ <br /> I have read and agree to the terms stated on the reverse side of DATE; <br /> <br />OWNER D A TF'¢ 0175't'Z%¢-; <br /> <br /> 7958 SF'ENCER I..N SE ~W: '{'UBS: [OOCUPAN'r LOAO: <br /> hdM,,V] , , <br />,UaE O¢ ~UILDING: NO OF BEDH00MS <br /> <br /> .... ............................ ..~ .... ~ ..................... <br /> MAILING ADDRESS; ~U~DIVtSiON: <br /> <br /> 2239 H F'~CIFC HWY NDBN '77~71 <br />! PI-I()NE: 769-774.4 VALUATION= <br /> <br />TYPE= OH-SITE SEWAGE WATER SUPPLY'- F'W <br /> TEST HOLES READY: YES <br />PERMIT OR APPLICATtOH HO: ?S&ll?l SITE EVALUATION HUMBER: <br /> EXISTINg TANK SIZE: <br />C,)F.I~AL~[)~,, HO, 34'~t6 EXISTING DRAIH FIELD LINES: <br />,:) ~ AY1 ON SEI' r.l.(, ::,,: ::SEPZI6 :,~ANK:: :PIJMf"ED: <br />4J. 15S STAYfON S6]:0 DR,SI~ PREVIOOS HO. BEDROOMS: <br /> <br />PHOi,IE: 769,-,2382 ' :':: <br /> QUANTITY AM(')UI,IT <br /> <br />RECEIPT NO: 63S26 <br />TYPE: CK <br />:'SYSTE~, <br /> <br />:YHE ~PPLZ6~HT TO ~SSLiF~E; TH~'F <br /> <br /> PAYF-E: STAYTON <br /> RECEIVED BY: CI <br /> <br /> S~:E A'f'FACHED DOCIJMENT <br /> * THIS IS ~OT A PERMIt. <br />~LI,. NEgESShRY ZNF,'ORHAT~O:N <br /> <br />;U!;M,flRK:',~'~ 'oA]'H)F: ,,I'EI~ (NO F'LY4NS)ADD,L, P£'F$ DIJG FOR REEVALUAT~(N~ ~LL,SUI{t~I'T SF:' F:'I ~],~!:: ! ' <br /> <br />OFFICE COPY <br /> <br /> <br />