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MARION COUNTY I~UILDING INSPECTION <br />SENATOR 8LDG, NO, 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-$147 8:00- 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am 13erforclltfl~l work on a property I own or occupy. <br />I am a t~i~ e~ed b~i[det OR the ~uthori~ed re~esentat ve <br /> <br />SIGNATURE OF APPk CANT <br /> <br /> 8;~51 KASA LN , <br />:~. ~,~.v.~ ................ oL_~_ ~..cou~r_~ .................. '. ........... <br /> <br /> ............................................ 1 <br />,~"L h~' ~D~ ........................................... ~"' ~ ...... <br /> <br /> PHONE: 74~-2~77 ~ VALUaTiON: <br />~,. ........................................................................ <br /> ] BLOCK: J SE¢IO~: ~ TOW~S~ IP~ ............ ; '~; ............... ~ ~6~ ....... [ MAP: <br /> <br />TYPE= 0H-SITE SE~Ar.E <br /> <br />PERHZT OR ¢~PPLICRTION 1,10: 57961 <br /> <br />CONTRACTOR. NO, <br />~A~ER~ CHUCK : .......... : ........... <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY: YES <br />SITE EVALUATION NUMDER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES= <br />SEPTZC'TANK'.PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> PHONE.' 749-207? ; <br /> <br /> ~TE, :-7 '7,- ..... T.--'~--. . 7'~ ......... ~;; ....... <br /> SITE EVALUATION, E~. ADDL. LOT"... ..... ' ' 1 <br /> · ; ' - · ~DTAL ASSESSED'FEES <br /> ' - '~ PRE:VIrUS ,RE~PT~ <br /> · ..': ':.' ...-.: ':'., "~,zs <br /> :: ...:....:...:.-; :...,:...:...., ;,,",,,,,,~:.. ~.~ ~& ... <br /> .......:. ;....7......:...?.r,,...:.:..... <br />P~Y~: .' ~.'::"J.-'"' - ........ R~c~zpr <br />RECEIVED ~Y: el_.. ' ~ :"' '"'"' ........'"'" ......TYPE: CHECK <br /> <br /> ...................... ~.. ~:_ ~T~_~___,~ _ ~__~'; ~ _~ ~ ................................ <br /> <br />,or~, ~N~S - ". '."'"',"::.:':"'"" ': ..... '" .' '..'. <br /> <br />OFFICE COPY <br /> <br /> <br />