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F~OR O~FF~CE USE ONLY <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> 2-20 High Street NE <br /> Salem OR 97301 <br /> <br /> 800om-430pm Phone 588-5147 <br /> Code-A-Phone 58g-Tg04 <br /> FAX 589-7948 <br /> <br /> SITE EVALUATION APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Location of Installation <br /> <br />Installation <br /> <br />3. Septic Information (Check where applicable) <br /> <br /> W,:tcr S[:pply Well [~ C[,y [] Spring [] <br /> <br />Site Evaluation t~ee $ / ~l~ <br />DEQ Surcharge ~/~2(~ <br /> <br />Receipt No <br /> <br />TotalAmount Du~-:: $ //~-.1 <br /> <br />Test Holes Ready: <br /> <br />Will Call When Test Holes Ready:: <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 septic installation begins. <br /> <br /> <br />