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MARION COUNTY BUILDING INSPECTION <br />SENATOR RLDG, NO. 2c'5 <br />220 HIGH STREET NE <br /> GALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 S:O0 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />~IGNATURE OF APPLICANT: .................... <br /> DATE: .................................. <br /> <br />S~HE <br /> <br />I <br /> <br />TYPE: ON-SITE SEIJAGE <br /> <br />PEI~IT OR P~PPi. ICATION <br /> <br />~(]HTRACTOR. NO~ <br /> ~EN~T~ LA~Y : <br />S~ME <br /> <br />PHONE: <br /> <br /> WATER SUPPLY: PW <br /> TEST H~LES, READY~ <br />5877~ SITE EVALUATION NUMDER: <br /> EXISTING TANK SIZE: 10BB <br /> · EXZSTIN~ DEAIN FIELD LINES= <br /> -~"SEP~{~,T~NK ·PUMPED= N~ <br /> I PEEVIOU$ NO. ~EDROOMS: 3 <br /> <br /> ITEM ,,. QUANTITY AMOUNT <br /> <br /> RECEIVED ~Y: DF ....... ~ ~ ~ ~ ....... TYPE: CHECK ~: 0 <br /> SEE ATTACHED DOCUMENT ~OE,·R[QUIREHENTS OF·'OH~SZTE ,SEWagE· <br /> * THI~ ~$ A VALID PERHIT':~;' ~H~s··P£i~'IIT EXPiR~S'·~%e' DAMPS FR~ ITS ISSUE O~TE. ~F <br />CONSTRUCT~OH FRILS TO HEET ALE"EEEU[EEHENT~' O~ STATE LABS ~N9 ~ARION COUNTY ~UILDIN~ AND <br />ZOHIN~ OR~INAHCES~ TH~S PERM[~:,,SI~ALC,,,~'ECO~E .'NULL 'AND VOID., , <br /> <br />REMARKS: AU:FLD ,' '" <br /> <br />OFFICE COPY <br /> <br /> <br />