Laserfiche WebLink
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 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />i am rerforming work on a property I own or occupy. <br />]anarep{seredbuilderOR( )theauthorizedrepfesentstive <br />of a registered builder. <br />The work wilJ be performed by 8 registered builder. <br />Other. <br /> <br /> I have read and agree to the terms ststed on the reverse side <br /> this document, <br /> <br /> OA'f~; 08/]3/91 'TIME: 14;23:24 <br />OWNER; <br /> ,"SH EPARD , 808~3Y <br /> <br />SfTUS ADDRESS: <br /> <br /> 9161 SMt'fH RD <br />AUMSV ~ LLE <br /> <br /> ' '~AX LOY; .......................... <br /> 5?658-000 F.-tl:,S I. [)~:N; ~/~L <br /> <br />97325 <br /> <br /> SAME <br /> <br /> PHONE:: ';'49~2407 ~ifE NUMBEIq: 4904- <br /> VALUA f iON; <br /> <br />LOT; BLOCK; ; s~c+m0~ ?~WNSHIP: ' RANGE: ZONE: ~ ~'. <br />WIOfH; DEPTH: AREA: 3- : ONITS: AC IRREG, LOT: NO coRNE~Io,, <br /> <br />'IMPE: OI~I~5IIE SEWAGE <br /> <br />F>E~,IMiI OR APPLICATION NO: 9034428 <br />OON'T RAC f'OR, NO, <br /> <br />~QNE: ?49-240? <br /> <br />WAFER SUPPLY: <br />'TES'T HOLES R,gAOY: <br />SITE EVALUAFiON NUMBER: <br />E:XIS'IiNG 'lANK SIZE: <br />EXiS'T'iNG DRAiN FiELO LINES: <br />SERf'iC TANK PUMPED: <br />PREVIOU~ NO. BEDROOr'~: <br /> <br /> l 'i EM QUAN l' i lY AMOUN'T' <br /> ANNUAL EVAL. - 'f'EMP OR Hf~P MH 'r <br /> <br /> 'TOTAL ASSE~EO FEES <br /> PRE¥iOUS RECEIPTS $0-00 <br /> 'T'Hi~ RECEIPT $60.00 <br /> <br /> BALANCE DUE $0-00 <br /> <br /> PAYEE: SHEPARO, BOSSY ~ ,REC~ZP'I~ NO: 3~296 <br /> <br /> SEE ATTACHED DOCU~EN'¥ ~OR RE(,~dtRE~EN~¥'~ 0¢ ON-~I'f'E ~ENA~E <br /> <br />~ THIS IS NOT A PEI~IlT. THiS APPLiCAtION I~UST (~O THRi~J~H A REVIEW PROC~..~x,~ ~-4ERE THE <br />~OLL.O~ING P~U~T B~ CO~qPL~T~D+ITISTHE RESPONSIBILITY OF THE APPLICANT TO ASS~R~ THAT <br />ALL NE~RY INFOR~IATION HAS ~EEN PR~¥IDED. <br /> <br />PLAN REVIEW; BY <br /> <br />DAlE <br /> <br />REMARKS: HARDHSIP RENEWAL R~3323 <br /> <br />Ci'fY JLJRi:SDJCfJON: E~Y .............................. DATE ........................... <br /> <br />FO,~M # MC 1~-~ REV. 4/~0 OFFICE COPY <br /> <br /> <br />