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6 <br /> MARION COUNTY BUILDING INSPP. CTI N <br /> 2,20 High Strut <br /> ' Salem, OR 97301 :. <br /> 8:00 am. 4.40 i~ <br /> C,.ode- A.lalxon~ 588-7904 <br /> <br />},'I'~ EVALIJATION AN~OR SEPTIC PERMIT APPLICATION <br /> <br />2. Contractor Information <br /> <br /> Pr OI3~¥ Owner <br /> <br />I DEQ Licensed Gontractcc & No. <br /> <br />Phone No. <br /> <br />l~one No, <br /> <br />Pumper Trock Inlx~ee'"on, e~_ ~dl, track <br /> <br />(M~k if Applleable to rAiu Application) q~ Bc4e.~ ~ Dug <br /> I will call when Te~t FZol~s ~g <br /> <br /> I am i~ r~gistcred broider ~ ( ) fl~ authofi~d rc~n~five <br /> oi'a registere~ b0ildor, <br /> ) Thc work ~ill ~ ~ff~ n~ by a DEQ l imn~gd lns all~r <br /> Other <br /> I agree to in,~t~tl acear~ng 1o ~ nubmitt~ plan~ ~d <br /> <br /> ot~nanc~ of Mari~ Coumy. <br /> <br />Rec¢ip[ No._ ....... <br /> <br />NAM~gI~~~.,OF APPLICANT C~ (Plia~ print): <br />SIGI~ATUI~ OF APPLICANT: <br /> <br />DATE: <br /> <br /> <br />