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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 hace read and agree to the terms stated on the reverse side of <br /> <br />DALE: 04/1I'/91 f i¢'4E: 9;45; 0,~ <br /> <br /> H(,)LOLiP3 E. K, ROE~R f <br /> <br />LOT <br /> <br />90221-150 <br /> <br />CATEGORY <br /> <br />SITUS ADDRESS <br /> <br /> ;800 ~SANf iAf'4 AVL <br /> <br />MAltING ADDRESS <br /> <br /> 2150 ~¢4IH AVE N~_ <br /> 'SALEM, OR 9'?303 <br /> PHONE.- 363-5578 <br /> <br />OR 9?342 <br /> <br />CON~TRUCTIO N TYPE <br /> <br /> CONTRACT CITY <br />OE~ ROi ~' <br /> <br />UGB <br /> NO <br /> <br />HAIVfqONO <br /> <br />SiI'E NU~ER: 32b'74 <br />VALUA F iON: <br /> <br />OCCUPANT LOAD <br /> <br /> 2 <br /> <br />tOf BLOCK SECTION TOWNSHIP RANGE ZONE <br /> 11 9 2 10 SE <br /> <br />WIDTH 50 DEPTH '~50 AREA '~'500. UNITS ~,~ IRREO tOT NO CORNEI:~o <br /> <br />MAP <br /> <br />ON-SI {E SE'WA(Cb. <br /> <br />Pf~F~TiT OR APPLiCA'rlON NO:: <br /> <br />CONfRACfOR, NO, <br />HOLOUBEK,ROBERf <br />2~50 34rE AVE NE <br /> <br />PHON~: 3~3-55'/8 <br /> <br />9031578 <br /> <br />WAFER SUPPLY: O~ <br />IESf HOLE~ READY: <br />~ifE bVALUAflON NUMBER: <br />EXiSflNG lANK SIZE: bS0 <br />EXISTING DRAIN FIELD LINES: <br />~P'IIC lANK PU~PEO: <br />PRE¥iOU~ NO. B~DROC]~q"o, ¢ ~ <br /> <br /> l 1 EM QuAN l I T Y AMOUN 1 <br /> AUIHORIZAflON NOflCE - FLO. ViSI[' q $?05.00 <br /> <br /> TO'IAL A~,,~E~ED FEES $ ~ 05,00 <br /> PREWi ~ RECEIPTS $0,00 <br /> IHIS RECEIP f $1OS_oL; <br /> <br /> ~ BA~C~ DUE $0_OE <br /> R~CEJVEO L~Y: O~2 ...................................... ~ fYPE: IN CH~CK ~: () <br /> <br /> ~ A[ IAOM~[) ~ENf FOR RE~IR~ENf'S OF ON-5IFE SEWAGE SYSfg~, <br /> <br />~ THiS 1S NOT A PE~iT. THiS APPL~Ti~ ~ST ~ TH~ A R~I~ P~ ~ERE THE <br />~GLL~ZN6 ~ST BE ~PLETED. iT ~S THE R~SIB~LiTY OF THE APPL~O~T 'rD ~RE THAT <br />ALL NEC~ iNFO~TI~ H~ BE~ P~V]DED. <br /> <br />RLNARKS: AU'IH - FIELD CHECK <br /> <br />CifY JUR!~JDICf[ON: BY <br /> <br />FO~ ~ MC ~S-S~ REV 4mo OF FICE COPY <br /> <br /> <br />