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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 />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am performing work on a property I own or occupy. <br /> <br />I have read and agree to the terms stated on the reverse side of <br /> <br />SIGNATURE O¢ APPLICANT: <br /> DATE: <br /> <br />OWN~'I'E: 09/'Il/gl <br /> <br /> KO'I"I'RE, RAY <br />SITUS ADDRESS: <br /> <br />limb: t2:U~:12 <br /> <br />TAX LOT <br /> <br />CONSTRUCTION TYPE <br /> <br /> 8612 SHAW C-QUAR~ RD <br />AU,~SVILLE OR <br />USE OF ~UI'LDING' ' ' <br /> <br /> SE CONTRACT C~T~ UGB: <br /> <br />...................... tYleR t ON' 'C'OUN 'f'Y ...... NO' <br /> <br />MAltING ADDRESS: <br /> <br />SUBDIVISION. <br /> <br />8613 SHAW ~ARE R~ SE <br />AUfvlSVILLE, OR 9?325 <br /> <br />LOI: BLOCK SECTION: <br />WIDTH. DEPTH' AR~A <br /> <br /> SiI'E NIUIV~8 ER: <br /> VALUA'[' i ON: <br />TOWNBRIP RANGE <br /> <br /> 8,5 2W <br />UNITS F1REG. LOT; <br /> <br /> &C NO <br /> <br />:CATEGORY: <br /> <br />AR3 <br /> <br /> RESI DEN T I <br />OCCUPANCY: <br /> <br /> 3 <br /> <br />MAP: <br /> <br /> ~9 <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERI'II OR APPLiCA'T'ION NOt 343,53 <br /> <br />CONfRAC'I'OR, NO. <br />KD]"TRE, RAY <br />86'13 SHAW SQUAR~ R~ Sg <br />AUMSViLLE, OR 97325 <br />PHON~; 364-2328 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES REAOY; YES <br />SiI'E EVALUATION NUt. ER: <br />EX~S'rIN6 rANK ~]ZE: <br />EXiS'T'iNG DRAIN FIELD LINES: <br />5EP'I'IC TANK PU~PED: <br />PRE¥iOUS NO. 8EDROO~S: <br /> <br /> IIEM OUAN'II'fY AI'flOUN'I' <br /> ~.['I'E EVALUAI'[ON, FIRS] LOT' 1 <br /> <br /> Fo AL A~E~ED F~E5 $ <br /> PREWDUSRaCe~P'FS $~?'5.o9 <br /> 'fFHl5 RECEIP'I' $0.00 <br /> <br /> BALANCE DUE $0_00 <br /> PAYEE; RECEIPT N0i <br /> <br /> ,.):~ ~flACHEB [YOCU~EN'f' FOR REQUIRE~EN"S OF ON~ITE SEWAGE SYS1'E~. <br /> <br />~ THIS IS A VALID PERI, IT * THiS PER~IT EXPIRES 360 DAYS FRO¢4 ITS ISSUE DATE. iF <br />C(~STi;~JCTION FAILS TO ~EET ALLREQUiREI4ENTS OF STATE L,.AHSAND I~AARION COUNTY BUILDING <br />iO~IN60ROINANCES. THiS PERI, iT !iiHALL BECOf~4E NULL ARC 1/OtB. <br /> <br />REMARKS: Sil~ ~VAL R~2504 S'I'O SYS'I'E~ <br /> <br />OONALO E. epL~JOLE.Y, MARION COUNTY BUILDING OFFICIAL / 8Y <br /> <br />FORM # MC 1~-86 R~V, 4/¢~ OFFICE COPY <br /> <br /> <br />