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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:$0 p,m, Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION APPLICATION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Location of Installation <br /> <br />" , - '-- ......... Cmss Street~ -' <br />Mobile IImne Pat~ Space ~ <br /> <br />2, Installation <br /> <br />Mail~g Address & Phone No. <br /> <br />Ma[lLn8 Address & Phone No, <br /> <br />Mailing Address & Phone No, <br /> <br />3. Septic Information (Check where applicable) <br /> <br /> Propos '~1 No, Bedrooms; Existing No, Bedrooms; <br /> <br /> Water Supply; Well ~ City [] Spring [] <br /> <br />Proposed Use: <br />Cemm: [] Office [] Wamhome [] Other <br /> <br />Fee Schedule <br /> <br />Site Evaluation Phc: <br /> <br />DEQ Surcharge: <br /> <br />Receipt No. <br /> <br />Total Amount Due: <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 />