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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 perforrtlin9 work on a property I own or occupy, , <br /> I am a registered builder OR the authorized represu~tative <br /> of a registered builder, <br /> The wErk will be Eertom/od by a registered builder. <br /> Other <br /> I have read and agree to the terms stated on the reverse side of <br /> this docurl~ent. <br /> <br />DATE; /0/31/91 TIME; '14t'~(]:5~ <br />OWNER: <br /> KCYS'I'A, PEARL <br />SITUS ADDRESS: <br /> <br />SIGNATURE O¢ APPLICANT: <br /> DATE; <br /> <br /> TAX LOT: <br /> <br /> CONSTRMCTION TYPE: <br /> <br />CAIEGORY: <br /> <br />OCCUPANCY: <br /> <br />RESI {DEN I iAL <br /> <br /> 10791 ARND'f' ROAO NE <br />AURORA OR 9?002 <br /> <br />dem-~Acr c~fY: usg: <br />MARION COUN' 'Y NO <br /> <br />OCCUPANT LOAD: <br /> <br />PHONE: B78-5965 <br /> <br /> 120: 120 14400. SP' <br /> <br /> SiTE NU~ER: 14624 <br /> VALUA'F i ON: <br /> <br /> !W AR <br />I~REG. LOT: CORNER; <br /> NO NO <br /> <br />1 <br /> <br />'tYPE: ON-SiTE SEWAGE <br /> <br />PER~iT OR APPLICATION NO: <br /> <br />CONTRACTOR, NO. <br />KO~'T'A, PPSARL <br /> <br />PHONE: 678-5965 <br /> <br />36242 <br /> <br />WATER SUPPbY: FAN <br />'rss'r HOLE,S R~AOY: <br />SITE EVALUATION NUMBER: <br />EXISTING 'rANK SIZE: 750 <br />EXiSTiNG DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> iTEM <br />REPAIR - MAJOR <br /> <br />TOTAL ASSESSED FEF_~ <br />PREVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />Ou~'rl'rY ANOUNT <br /> $85.oo <br /> <br /> ~85.00 <br /> 85.00 <br /> $o.oo <br /> <br />BALANCE E~.JE $0.00 <br /> <br />PAYEE: RECEIPT NO-* <br />RECEIVED BY~ GL2 'tYPE: CHECK ~: 0 <br /> <br />SEE ATTACHED DOCUME~'F FOR REQUIRENENTS OF ~I'FE ~A~E SYS'I'~. <br /> <br />~ THIS I~ A VALID PE~iT ~ THiS P~ZT ~PiR~ 360 OA~ ~ iTS I~E ~TE. iF <br /> <br />CONSTRUCTION FAILS TO MEET All RF_QUIR[EflE~TS OF STATE LAH~ AND FtARION COJNTY 8UILOING ,aJ~D <br />ZONING ORDINANCES,. THIS PER,lIT SHALL B~E NULL ANO VOID. <br /> <br />RE:jV~ARKS: SEPTIC REPAIR 'rANK & DRAiNFIELD R~3774 <br /> <br />DONALD E. VFOODLEY, MARION COUNTY BUILDING OFFiCiAL / BY <br /> <br />OFFICE COPY <br /> <br /> <br />