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SALEM, OREGON 97301 <br /> <br /> PHONE 588-.5147 <br />CODE-A-PHONE 4:30 PM. - 8::00 A.M <br /> <br />lama registeredbuHderORll )theauthorfzed representative <br /> <br />SIGNATURE OF APPLIQANT <br /> DATE <br /> <br />o~¢~'~: 10/0t/87 TIME: <br /> COLUrCt3 IA HELICOPTERS <br /> <br /> 14452 ARNDT RD NE <br />,~LJROR.A OR 9?002 <br /> <br /> I TAX LOT <br /> <br />I: CONTRACT CITY ! UGB <br />MAdiSON COWNTY ..... NO- <br /> <br /> CATEGORY <br /> <br /> COMMER [CAL <br />'OCCUPANCY <br /> <br />SITE NUMBER: <br />. VALUAT I QN: <br />'~ RANGE <br /> <br /> lW <br /> ~RR~O LOT <br /> <br /> NO <br /> <br /> 02 UNITE -4S · <br /> <br />3.00000 , AC <br /> <br /> 1535 <br /> <br /> P <br /> <br />YES <br /> <br />MAP <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERf~1IT OR APPLICATION NO: <br /> <br />CONTRACTOR, NO. 233?2 <br />FRED DOLSB~ <br />2690 OXFORD ST <br />WEST LINN, ORE 9?068 <br />PHONE: 655-6956 <br /> <br />9004726 <br /> <br />WATER ,.'TAJPPLY: <br />TSS? HOLES RE. ADY: <br />SITE EVALUATION NUI~BER: <br />EXISTING TANK SIZE: <br />EXISTiN~ DRAIN FIELD LINES; <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. 8EDROOIVLS: <br /> <br /> ITEM QUANTITY AMGt~NT <br />STP ONSITE S¥S < 1000 GAL 1 $125,00 <br /> <br /> TOTAL ~ED FEES $125.00 <br /> PREVIOUS RECEIPTS $0,00 <br /> :]THIS RECEIPT $!25_00 <br /> ,BALANCE DUE $0,00 <br />PAYEE: FRED DOLSEN ~ ~ ~ RECEIPT NO: 5286 <br />RECEIVEO DY: dB ......... ~~__ TYPE,OK CHECK ~: <br />~"Z~; '~J~"~---~---~~REQUIREMENT;-~ ONZ~¢E' ~-~T~] ...................... <br />~ THIS IS NOT A P~R~IIT~ THIS ~PP~ICAT~ON IvIUST ~O THROUGH A REVI~ PROCF_~ ~£R~ THE <br />POLLO~NB i~UST 8E Cx~4PL~rED. IT I$ TH~ RE~i~B~k~I'Y OP THE APPLIC~IT TO A~URE THAT <br /> <br />ALL NECESSARY INFORI'~ATION HAG BEB~ PROVIDED. <br />REMARk: REPAIR <br /> <br />CITY JURISDICTION: <br /> <br />OFFICE COPY <br /> <br /> <br />