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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO, 225 <br />220 HIGh'STREET NE <br /> SALEM, OREGON 9'7;301 <br /> <br /> PHONE: 588-5147 8:00- 4!30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 ~,~ <br />i am performin§ work on a property I own or occupy. S ¢~..~,~ L <br />I 8m a registered builder OR ( ) the authorized reBresentatlve $1GNATBRE OF APPLICANT ' ¢' <br /> <br />The work will be performed by a registered builder, <br />Other__ ' ~ <br />I have read and agree to the terms stated on the reverse side of BATE: <br />fhis document. <br /> <br />°w~,~TE: 09/2'_5/99 TiIVIE: 13:54.'~3 <br />SITUS ADDREB~I~;;~'~"EI~R;. BERNARO <br /> <br />, TAX LOT: <br /> <br />; CATEGORY: <br /> <br />OCCUPANCY: R~Si <br /> <br />852] HOL,I~IOUiST RD SE <br /> <br />~,AR iON COUNTY NO <br /> <br />MAIUNG ADDRESS: <br /> <br /> P-O BOX 255 <br /> 5UaLIMi'f'Y, OR 97385 <br /> PHONE: '789-2139 <br />LOT: BLOCK: <br /> <br /> SI'IE NUMBER: 19U9 <br />SECfi0N: :TOWNBHiPi Rxr~f.~LUA'¥'ION:zONE: MAP: <br /> <br />WIDTH: <br /> <br />DEPTN: ,AREA: 31 UNITS: ~S ;~R~s. LOT: -~ :CORNE~: AR <br />! ? ~ ~ NC! ', NFl <br /> <br />4-8 <br /> <br />'TYPE: ON-SITE ~ENAGE [ WATER SUPPLY: PW <br /> TEST HOLES READY~ <br />PER~!!' OR APPLiCATiON NO: 9027508 ¢~¢%S!')'~ EV~[.UA']'~ON NUMBER: SE83~1959 <br /> · , , (}kL)EX~S'EtNG 'F,~,NK <br />CONfRACTOR, N(~. 359]~ ,-~'"\1 ~XiSTANG BRAIN FIELD LINES: <br />S'fAY'fON MiLL CN'¥ ~tLVER'I'O~ SEP ,,.~)~,L.~ /SEPTIC TANK PUMPED: <br />41155 S'!'AYFON SCtO DR~VE, SE ,., ~"~ I PREV~OLIS NO. BEOR('X3~5: <br />b'fAY'f'(}N,, OR~ 91383 ~ ~ <br />PHONE: ~$9~2302 ~'2 <br /> <br /> I'FE~ QUAN'f'~'f'Y ~OUN'f <br />PRESSURE DiS'FRIBUIION 1 $'185.00 <br /> <br /> TOTAL A~,SE~ED FEE~ $165.00 <br /> PREVIOUS RECEIPTS $0_00 <br /> THIS R~CEIP'f' <br /> <br />BALANCE DUE $0.00 <br /> <br /> PAYEE~ RIES'I'ERER, BgRNARO 29'!95 <br /> R~CEiVE[) BY: PR TYPE: CK CHECK ~: 1057 <br /> <br /> SEE ATTACHED DOCUNENf FOR ~EQU~R~I~8~'I'S OF <br /> <br />~ THiS J8 NOT A ¢ERNtT. TH~$ APPLJCAI'~ON IVlUST GO THROU6H A R~V~EN PROCESS NBERE THE <br />~OLLO~JNG IVC3~'F BE COMPLETED. ZT ~$ ~HE RESI;;'ON$&BZLJTY OF THE APPL~CAN'f' TO ASSURE THAT <br />ALL NEc-E...~ARY INFQf:~,IATiON'HAS SEEN PROVIDED. <br /> <br />RECEiP'f NO: <br /> <br />PLAN R~VIEW: BY..,,~ I;A:'~ ....... l~(~"~ <br />REffiARKS: PR~SURE DiS'FRiDU'I'ION 1~3311 <br /> <br />CiTY JURISO!,C]'ION: BY <br /> <br />0A'I'E ..... <br /> <br />OFFICE COPY <br /> <br /> <br />