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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, ©FiEGON 97301 <br /> <br /> PHO~IE 588-5147 <br /> CODE-,'~:PHONE 4:30 P.M, - 6:00 A.M. <br /> <br />lamareg~steredbuilderO~( )theauthorlzedrepresentative <br /> <br />I have read and agree to the terms Stated oh the reverse side of <br />this document, <br /> <br /> UGB <br /> ~ ' "~.' ' ¢.t ,. ,,¢ I' .... U ¢,,,,,A,.. <br />,B~_,¥¢,3'¥ i ]_=E .......,c4 ~ ~ .¢ ~,,,, <br /> <br />LOT. BLOCK BECT'4~N: TOWNSHIP RANGE <br /> <br /> -977 <br /> <br />ZONE· <br /> <br />WlD} H: DEPTH' AREA· UNITS: ~'~ RREG. LOT <br />~ ~ <br /> <br />CORNER <br /> <br />~354 <br /> <br />NATER SUPPLY; PN <br />TEST HOLES READY;: <br />Si'T~ EVAi...UAT-~ON NUMBER: <br />EXIST !NS TANK <br /> <br />SEP'[IO TANk PL!'"/PED:: "-',,:.¢'-8,; <br /> <br /> ;, TENt Ot.,;ANi <br /> <br /> PREVIOUS RECEi?F5 GL:,2. <br /> <br /> , BALANCE DUE $ <br /> <br />R&YGE' ~ECEZPT <br />RECEIVED aY: ,JZ; ................. ~ .................. <br /> <br />b~STR~CTi~ FA~LS TO.~E~ A~L RE~IR~TS, O~ STATE <br />~C~i,~G ORDiN~CcS, %ff~S ~E~.T ~ALL 8E~E NULL A~ND VOID. <br /> <br />:~.~. MC *SSS ~[V ~/~/ OFFICE COPY <br /> <br /> <br />