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FOR OFFICE USE ONLY <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:00 a.m.-4:30 p.m, Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Location of installation <br /> <br />l.ot Wid? I~[~ep~ Acm~ Iaeg, L~ : <br /> <br />2. Installation <br /> <br />Mailing Address & Phone No. <br /> <br />Mail's Address ~ }~one NO, <br /> <br /> Contractor Rusine~ Nam~ & Number Ma[lh~g Address & Phon~ No, <br /> <br />3. Septic Information (Check where applicable) <br /> i'mpo~d No, 8edr~yorns: ,~.~ Existing No, Bcdrcom~: O <br /> Water Supply: Well ,~ City [] Spring [] <br /> <br />Res: [] Singk~ Pamily Dwelling [] Accessory Structure [] Other <br />Corem: [] Office [] Warehome [] Other <br /> <br />4. Fee Schedule <br /> <br />DEQ Surcharge: <br /> <br /> Total Am.unt l)ue: <br /> <br />Receipt No. __ <br /> <br />Test Holes Ready: <br /> <br />Will Call When Test Holes Ready: <br /> <br />Si~_,nn trc o f Ow ~er ¢ r Authorized Agc~/.~;~zZS~/c_.. <br /> <br />This is a technical report for on-site sewage disposal only and does not grant or <br />imply permission to build on this parcel. Planning approval, construction and septic <br />permits must first be obtained before building or s~-ptic installation begins, <br /> <br /> <br />