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MARION COUNTY BUILDING INSPECTION <br /> SE"~ATOR BLDG, NO. 225 <br /> ' '" 220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE 588-5147 <br /> CODE-A-PHONE 4:30 RM, - 8:00 A,M, <br /> <br />I am a registered builder OR ( ) the authorized represeRtative 81EINATURE OF APPLICAN 2 <br /> <br />°WN~ATE: 04/2?/90 TIME: <br /> <br />SlTUS^DDnESs:DALY. ALLEN E. <br /> <br />10;05:34 <br /> <br />TAX LOT: CA'fEGGRY' <br />CONSTRUCTION TYPE: OOOU?ANCY: <br /> <br />RESI DENT I AL <br /> <br />23861 SCHULTZ RD NE <br /> <br />OR 97002 <br /> <br />CONTRACT CITY: UGB: <br />~,IARI ON COUNTY NO <br /> <br />OCCUPANT LOAD: <br /> <br /> NO. QF BEDROOMS: <br /> <br />SUBDWiSION~ <br /> <br />2 <br /> <br />LOT: <br /> <br />13023 SW ROGER RD <br />PORTLAND. OR 97218 <br />~4ONE: 639"5351 <br /> BLOCK: <br /> <br /> SITE NUf48ERt 8781 <br />RANGEVALUAT I ON :ZONE: <br /> <br />MAP: <br /> <br />WIDTH: DEPTH: AA~A: <br /> <br />32 UN,TS; <br /> 1.5 <br /> <br />9S IRREG. LOT: 1W CORNE~: AR <br />AC NO <br /> <br />.! <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION NO: 90235?8 <br /> <br />CONTRACTOR, NO. <br />DALY, ALLEN E. <br />13023 SW ROGER RD <br />PORTLAND, OR 97219 <br />PHONE: 639-5351 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: 5-?8-? <br />EXISTING TANK SIZE: <br />EXISTING DP~AiN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> ITEM ~ QUANTITY AIvlOUNT <br /> STANDARD ON-SITE SYSTEM ~..,~L) 1 $165_00 <br /> TOTAL ASSESSED FEES $165.00 <br /> %i,'%~';~ PREVIOUS RECEIPTS $0.00 <br /> THIS RECEIPT $165_00 <br /> <br /> BALANCE DUE $0.00 <br /> <br /> ~AYEE: DALY. ALLEN E. RECEIPT NO: 29.979 <br /> RECEIVED BY: c] TYPE~ CK CHECK ~: 4140 <br /> <br /> SEE ATTACHED DOCUMENT FOR REQUIRE~ENTS,OF ON-SITE SEWAGE SYSTEM. <br /> <br />~ THIS IS NOT A PER~IT. THIS APPLICATION MUST GO THROUGH A REVIE~ PROCESS WHERE THE <br />FOLLOWIN6 MUST BE COW1PLETED. IT IS THE RESPONSIBILITY OF THE APPLICANT TO A.SE~URE THAT <br />ALL NE~CEE~SARY INFORI~IATION HAS SEEN PROVIOEO_ <br /> <br />PLAN REVIEW: 8Y,,,,~.(~,, ....... <br />REN1ARKS: SEPTIC <br /> <br />CITY JURISDICTION: BY DATE <br /> <br />FORM C~ MC15-56 REV. 11/8~ OFFICE COPY <br /> <br /> <br />