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MARION COUNTY i~UILDING INSPECTION <br />SENATOR SLDG. 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: 5~-7g04 <br /> <br />I am performing work an a property I own or O~upy. <br />l am a ~egistered builder OR { ) the suthorl;t, ed feDresentatlve <br />of a regls~eted b~Hder, <br />The work will be pedormed by a regi3terCd b~ildec <br />Other ............... · <br />I ~ave read and agree to the term~ stated o~ t~e reveme si~e of <br /> <br />SIGNATURE OF APPLICANT:~ <br /> <br />DICK <br /> <br /> i318& HORRAY [.ARE NE <br />AURORA OR 97002 <br /> <br />RESIgENT~4i_ <br /> <br />TYPE; <br /> <br />MARiOH COUNTY NO <br /> <br />OCCUPANCY; <br /> <br />~CUPANT LOAD: <br /> <br />TYPE: ON-SITE SEWAGE BATER ~UPPLY: PN <br /> TEST HOLES READY: <br />PERMIT OR APPLICaTiON NO: ?tl52~&0 ~TE EVALUATION NUMBER: 34389 <br /> EX~STING TANK SIZEt <br />CONTRACTOR. NO. EXISTIN~ DRAIN FIELD L~NES: <br />PERKETT~ DICK .~ ~..~.=,.~, ...................... ~I~.. ~ANE,.~'UMPEDD <br /> PReViOUS' NO. B~'~DRO0~: <br /> <br />PHONE; 2~.~6-.9592 <br /> <br /> ITEM D ,,~ <br /> STANDARD ON-SITE <br /> <br /> ¥ <br /> PAYEE~ M(DI~,~ ~'or <br /> RECEIVED BY: pD <br /> SEE ATTAGHED DOCUMEN~- <br /> ~ THIS I~ NOT A PERH] <br />FOLLOWING HOST BE COMPi <br />ALL NE(;ES~ARY ~NFORHA' <br /> <br /> QOANTiTY ANOUNT <br />', <br />" 1 $~. <br /> <br /> ~255,,0~ <br /> $255.88 <br /> <br /> RECEIPT NO:. 54815 <br /> TYPE: CK CHECK ~: 2580 <br /> <br />A REYZE~ PROCE~ WH[RE THE <br /> APPLICANT TO ASSURE THAT <br /> <br />:o~u ~ t~c ~.~ ne/, ~ OF FICE COPY <br /> <br /> <br />