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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO, 225 <br />220 HIGH STREET NE <br /> SALEM. OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588*7904 <br /> <br /> I am a reglste?e~ builder OR ( ) the authorized reOresehTat Ye <br /> of a registered builder, <br /> T~e work win be 0er~0,med by a r~istered builder. <br /> <br />OWNER~ <br /> ~OIJTHERL~ND, GENE <br /> <br />11708 DONALD RD NE <br /> OR 97~82' <br /> <br />PHONE: 678-5744 <br /> <br />SIGNATURE O? APC't, IOAN?: ................ <br /> <br /> ' }~ LOT: .......... <br /> <br />.... N--'¢~,'-7~[' '. ....... T-O'¢'r':' ....... <br />:Cf'lO~l~"f~l ~UNTY; NO <br /> <br />5~TE iI~JjN~EI~: <br />VALUATION= <br /> <br />: RESIDENTIAL <br /> <br /> OOC~P~NOY: <br /> <br />NO OF- BEOROOMS <br /> <br />'FYPE: ON-SITE DELUGE <br /> <br />PERNIT OR APPLZr_.ATIOH <br /> <br />CONTRACTOR. NO. <br />SOUTHERLAN~ GENE <br /> <br />PNONE= &Ta~5744 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES~ <br />SEPTIC TANK PUflPED~ FORM <br />PREVIOUS NO. ~EDROOMS~ <br /> <br /> ITEM 9UANTITY AMOUNT <br /> REPAIR = MINOR '~ 1 $85.00 <br /> AUTHORIZATION NOTICE - FLD.:..~'[S'IT I $160.00 <br /> <br /> · '.:..... : ..... TOTAL 'A~ESSED 'FEES $245 <br /> ' ' .THI. S. RECeIpT <br /> , ...... ..-,, <br /> <br /> PAYEE: RECE[P'r NO: <br /> RECEIVED BY= CL ' ' <br /> .................... TYPE: CHECK ~: <br /> ....... _ .__ ..._.::::__:__:__:__::':=-- _:_Z__: ............................ . <br />SEE ATTACHED DOGUMENT,"FO~ REQUIREHENT~'OF OHTOITE SEWAGE' SYSTEM. <br />~ THIS ~ ~T A ~T. ":'.THIS"B~Ti~=~'.~ T~ A REV~E~ PR~ ~E THE <br />FOLLOWING HUST 9E OOHPLETE~; ~T '~9,~THE 'RESPONSIBILITY OF THE APPLICANT TO ASSU~ THaT <br />ALL NECESSARY INFORMATION .HA~ ~EEH PROVIDED. "' ' <br /> <br />OFFICE COPY <br /> <br /> <br />