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I FOR CITY USE ONLY I MARION COUNTY BUILDING INSPECTION <br />o ~ COMMUNITY DEVELOPMENT CENTER <br />· Received By: 285 ChurchSt. NE - Room 132 <br /> .... ' ~ . [ Salem, Oregon 97301 <br /> Zoning Vahdatton: ~ /~c3 8:00am-4:30pm Phone 588-5147 <br /> Date' / ~' c::,~-'~ ~ ~/..../~/~}'~ ~l)r. Inspection Line 373-4427 <br /> I ' -- -' g' I [~; L./c/-7' ) ~- FAX588-7948 <br /> SITE EVALUATI~-"N J(ND/OR SEPTIC PERMIT APPLICA~rO~.. <br /> 1. LOCATION OF INSTALLATION <br /> <br />Job Address / Tax Acct. No. ~D~& /~ ~O Cross Street <br />Su~ivislon ~' /~ Z Bilk ~ No. Employ~s -- O ' <br /> <br />Section ,OZ Towns~p /~5 Range %~ Zone Ma~'o ~e Oa~ Wa~rSupply: <br /> ~vate Well ( } Spring <br />LotWidth /0~. , ~ LotDepth /~ ~ A .... ~/~ I~eg. Lot ~ C ..... Co~unityWell ( ) Cilv~ <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />3. FEES <br /> <br />Mailing Address~OO ~ ~S- ~}l./,,~ Phone <br /> <br /> Sand Filter System ............................................................................................................................. 703.00 <br /> Steep Slope ......................................................................................................................................... 382.00 <br /> <br /> 600 gallons - 1000 gallons .............................................................................................................. 133.00 <br /> 1000 gallons - 2500 gallons ............................................................................................................... 133.00 <br /> <br />Name of Applicant (Please P~n~. ~/e~S ~He~M~' <br />Signature of Applicant: _~_~'~ <br /> <br />+ $100/500 gallons <br /> <br />+ $25/500 gallons <br /> <br />+ $25/500 gallons <br /> <br />~7~.oo <br /> <br /> · o,ZS// ~,YO <br />Test Holes Ready: <br />Tank Pumped: 7 <br />Pumping Certification Attached: ~ (N) <br /> <br /> <br />