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MARION COUNTY BUILDING INSPECTION
<br />SENATOR BLDG. NO. :~25
<br />220 HIGH ~TREET NE
<br /> SALEM, OREGON 97301
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<br /> PHONE: 58~5147 8:C~3- 4:$0
<br />24 HOUR CODE-A-PHONE: 588-7904
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<br /> am per orm ng work on a oroDer~ I own or
<br /> i am a r~ietered builder OR ( J the euihori~ed representative
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<br />................ ~Ig~J, bZ~Z ?.~ .......... ~,~ .. ~,~5.~ ~,,.
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<br /> 15~ SCOTT AVE ~ ~t~ c~,m
<br /> ~ETROtT OR ~7~4. ~DETROIT
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<br />SIGNAYURE OF APPL1D~ANT;,~.~ .......................................................
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<br /> P.O. BOX 577 ,~
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<br />' o . ~ R~ ......
<br /> ~/~ ~ ~. ~ ~ ~ l~ t ~ ..... j ................ j
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<br /> YES ~ -- :
<br /> ~le'~ l~] ~i~. ~ SF ~ ~O , l-.--~: ......... ,,. ....... :~,,- ..... , ...........
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<br />TYPE: ON-SITE
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<br />CONTRACTOR. NO,
<br />GAGATKO. DONALD J.
<br />P.O. BOX 577
<br />DETROIT, 8~ 97342
<br />PHONE=
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<br />8ATER 8UPF'LY: CM
<br />TEST HOLES READY: YES
<br />SITE EVALUATION NUMBER:
<br />EXISTING TANK SIZE:
<br />EXISTING DRAIN FIELD LINES:
<br />SEPTIC TANK ~UMPE~:
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<br /> , ITE~ . (~UANTITY AMOUNT
<br /> PERMIT RENEWAL ~ NO ~I$IT . ',, :' · :' ',,,",:..j' ...' ',,.. ',':,,,': . 1 $95.
<br /> ; ':'il.....: :'.'.,. :;.:' · ': .':.:'.:.':'.':-'-i~.~:,A~S[*~E~; F~S ~.
<br /> ' "'" ' .= .'. · ':,-"~RE~'~US,RE¢~PTS
<br /> ': ',, '-: "'. ',.~ ~ ,..'.'. '.}:, ':-:-~<";';" ~:H~:":RE~:~'P~:':'::;4 . $~5.
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<br /> PAYEE: ~AGAT/O~ 30NA['~ ~... :. ,' ,....~ ....... '::~:,,:',;~;.i::',?',~;;,.:~..::.,;.:':::..::'?'.' '.: INVOICE NO: 49809
<br /> RECEIVED BY: PM2 ..: ; :,';..:..".,g .::-'.: ,, .,7. ,,,:,:: ........ ' "'..'...< "',' TYPE~ IN CHECK f:
<br /> SE2 ATTACHED DOC~MEN!,. FOR~REQU]/REH[N,T8 :o~,. ,ON-$~%E ..$EWAGE,,$Y~TE~.
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<br />FOLLOWING MUST DE COHPL~Eb'~;~:,I,? ~.,,TH[/,'RE~PO~.IBI~ITY"OF"THE APPLICANT TO ASSURE THAT
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<br /> R~'MARK~ ~EPTZC~r,rKI,~[.~.~F2R ~ERMZT ~ g2~B.6 - NOI~ PERMIT ~ 4~418 - NOT VALI~
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<br />OFFICE COPY
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