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FOR OFFICE USE ONLY <br />R¢c~ivep!, By: __ <br />Zgain~ Validation <br />Da~e: <br /> <br />1. Location of Installation <br /> <br />MARION COUNTY BUH~ING INSPECTION , <br />220 High ~t~.~ NE <br /> Salem, OR 97301 <br /> <br />SITE EVALUATION AND/OR SEPTIC PERMIT AI~PLiCATiON <br /> <br />.~2: Co~ factor Inf0rmatmn <br /> <br /> ' ~5,00, 20,O0/m <br /> ~ 2~.oo, . io.oo <br /> ' "" ' 2~J.0e: ~, 10,~ <br /> <br /> . 245,~0 i 10,09 , <br /> 245.00 <br /> <br />.......... * 10.00 <br /> <br /> Slte E~G~ion~ ~t lot , ~ 245~00 . 20~00 <br /> <br />' '~!~k · ' .' 245,00 1~,~ <br />~ ~valu~Al~mativc Sys~m 1S0,00 ,00 <br /> <br />(Mark it'Applicable to thi~ Application) : <br />( )Te~tHolcsarcDug ' ; ; "" '"" ..... ' '" : ' ' ',' <br />( ) I will ~all when Teat HOI~6 Dug ~ ,,, <br /> <br />NAME OF APPLICANT (please print): <br />SIGNATURE OF APPLICANT; DATE: <br /> <br />MC I$-SI REV 2/93 <br /> <br /> <br />