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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO, 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br /> <br />I am performing work on a property I own or occupy, gl~l i¢:~jT/~'~ ._ <br />l amaregisteredbuilderOR( ) the authorized representative SIGNATURE OF A~,~///, <br />of a registered builder. <br />The work will be performed by a registered builder, <br /> <br /> Other .... <br /> I have read and agree to the terms stated on the reverse side <br /> ~hi8 document <br /> <br /> DATE: 08/2?'/90 TIME.' <br />OWNER: <br /> <br /> AU~ ~O2 <br /> <br />USE OF BU{LDING: <br /> <br />MAILING ADDRESS: <br /> <br />NE <br /> <br />PHONE.- 6?8-2700 <br /> <br />LOT: BLOCS: <br /> <br />WIDTN: DEPTH: <br /> <br />DATE: <br /> <br /> i' ~(~N~RAO:r C[TY: <br />1'4AR i ON QC.,~N I'Y <br /> <br /> SITE NUFIBER~. <br /> VALUAT iON: <br /> <br />: SEDTION: I TOWNSHIP'. : RAH'GE <br /> 23 4S <br /> <br /> EFU <br /> <br />YES CORN ~'~O <br /> <br /> CATEGORY: RESIDENT 1AL" <br /> OCCUPANCY: <br /> <br />:OCCUPANT LGAg' <br /> <br />MAP: <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERf~i'I' OR APPLICATION NO= <br /> <br />OC~'['RACTOR, NO. <br />SCHUEN iNG, iVAN <br />sAME <br /> <br />PHONE: 678-2700 <br /> <br />9026753 <br /> <br />WATER SUPPLY** P~ <br />'rEST HOL~ READY.* / <br />SiTE EVALUAI'TC~I,~ ,.NdIv~ER: <br />E,~(ISTINS TANK SIZE** <br />EXJ[SI'INS DRAIN FIELD LINES: <br />SEPTIC 'rANK PUMPED: <br />PRE~CIOU5 NO. BEDROOf~3; <br /> <br /> 1TEN QUANT i TY AI~C~JN 1' <br /> REPAIR - Iv[a~JOR 1 $80~00 <br /> TOTAL. GE.fEE. ED FE¢,~ $80. OD <br /> PJq~V'l:~ · RECEIPTS SOt 00 <br /> THI~' R~OEiPT $80+ O0 <br /> 8A~CE ~E $0.00 <br /> <br /> PAYEE: ~ING, lV~ RECEIPT NO: 28301 <br /> RECEIVED BY= cl TYPE= CK ~ECK ~= 1588 <br /> <br /> SEE AT'rA~ED ~'r FOR SYST~. <br /> <br />~[~ ~ST BE ~- IT ZS=THE ~[B[L[~ OF ~E APPLt~T TO ~RE THAT <br /> <br />R~RKS: REPAIR R'~3993 <br /> <br />CITY JURISOIC't'ION: BY ............................OATE ............................... <br /> <br /> OFFICE COPY <br />FORM # MC 15-~ REV, <br /> <br /> <br />