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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 H~GH STI~EET NE <br /> SAL6M, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I 8m a registered builder OR ( ) the authorized representative ~IGNATURE <br />of a registered builder, <br /> <br />O,her / <br /> <br /> gAl'E: 10/21/91 'I:LME: 12~06:58 <br />OWNER: TAX LOT: CATEGORY: <br /> <br /> K~'I A, PEARL <br />EI~UD ADDRESS: OONST~UCTION TYPE: O~OUPANCY: <br /> <br />REStOENIIAL <br /> <br /> 10791ARND'F ROAD <br />AURORA <br /> <br />PHONE: 8';¢8-5955 <br /> 180 <br /> <br />Si NUMBER: <br /> : ZONE: <br /> <br />120 ~00. <br /> <br />:OCCUPANT LOAO: <br /> <br /> NO OF BEDROOMS <br /> <br /> 3 <br /> <br /> 14624 <br /> <br /> AR <br /> <br />NO: NO <br /> <br />'TYPE: ON-SITE SEWAGE <br /> <br />PERJvIj'f OR APPLiCA'I'iON NO: <br /> <br />C~N'f'RAC'f'OR, NO. <br />KOS'¥A, PEARg <br /> <br />PHONE*. ~78-5965 <br /> <br /> SUPPLY: P~ <br />HOLES RS~a~OY: <br />EVALUATION NUIVE~ER: <br />EXiS'T1NG 'TANK SIZE: <br />E~S'I'ING DRAIN FICLO <br />SEP'rIC TANK <br />PREVIOU~ NO. BEOROOI'4S: <br /> <br />AUTHORiZATIO~ NOTICE ~ FLD. ¥] <br /> <br />PAYEE: PEARL KOS'f'A <br />RDCEIVEO BY: O~2 <br /> <br />~EE AT'f'ACHEO DOCuMPj'4'f' <br /> <br />~ THIS 13 NOT A PEI~iT. <br /> <br />Q1JANTI1'Y AMOUNT <br /> 1 $110,00 <br /> <br /> FEES $110,00 <br /> RECEIPTS $0-00 <br />'f'HI~ !1P'¥' $110,00 <br /> <br />BALANCE $0,00 <br /> <br />REr,.,~tJIRf~ENTf5 OF ON-SITE <br />THIS APPLiCATiON i~UST GO <br /> <br />RECEIPT NO: 38155 <br />CK CHECK ~: 4093 <br /> <br />SYS'rEr4. <br /> <br />AREVlEI~ PROC~ ~HERE 'f'H~ <br /> <br />~OLLO~ING I~UST BE COf4PLETED. iT ISTHERBSF~BNSISILiTY OF THE APPLIC~4T TO A,.5,.~JRE THAT <br />,ALL NIECrc;~;:xARY iNFO/;~I, TION:NA~BEI~/ PROVIDED. <br /> <br />PLAN REViEN: 8Y ..................................... DATE ................................... <br /> <br />REMARKS: AU'TH ~ FIELD ViSiT R~'774 <br /> <br />CiTY JURISDICTION: BY ............................ CA'rE <br /> <br /> OFFICE COPY <br />FORM # MC 15-56 REV, 4~ <br /> <br /> <br />