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' FOR CITY USE ONLY <br />Rfceived By: '~(-~ __ <br />Zoning V~lidation: __ _ <br />Date: ..................... <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITy DEVELOPMENT CENTER <br /> 285 Chumh St. NI~ - Room 132 <br /> Salem, Oregon 97301 <br /> 8.~00ama:30pm Phone 588.$147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br />RECEIVE <br /> <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />L LOCATION OF INSTALLATION <br /> <br />Zone Map <br /> <br />No. Employees <br /> <br />Existing NO. PtoIJo~ed N~J. <br />Bedrr~ma <br /> <br />Water Supply: <br />~ivate Well ( ) Spring <br />Community Well ( ) City <br /> <br /> Mailing Add.as , Phone NO. <br /> Mailiug Address Phone NO, <br /> <br /> MaiIing Add~esl Phone No. <br />3. FEES <br /> <br /> Gray Wa~r Disposal Sump ................................................... ~ ........................................................... 195 00 <br /> <br /> si.~]~ ~a~ily D~I,~, Ml,,o~ g~i; (~';~i;~:;..:.:::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::: <br /> S~ng[~ FamiIy ~lJing, Majo~ R~pa r (dr~ n~c d) ........................................................................................................ ~1~,00 <br /> <br /> Septic Inspectkm tbr .... which no fke ~is specifically indiea~d : " .................................. ~ ~e--q --~ ~:';'~ ~ ~ ..... 'rota]:~~~' <br />Nameot'Applicant(Pleasa.int): O~ ~ ~ ~05~ Test Holes Ready: ~~ <br />$lgllature Of Apphcam: ~~ /~ Tank P~p6d <br /> <br /> <br />