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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO, 22B <br /> 220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br /> 24 HOUR CODE-A-PHONE: B88-7904 //~ . <br /> II ~nr~ aP~(~irsr~dWbcuri~d°er~ ~)l~r°pert~Yela°u~l~o~irz%~lcruG'%Yr'esentabve SIGNATURE OF APPLIC~~- ¢ ~ <br /> I have read and apree to tl)¢ terms stated on the reverse side of DA~E: <br /> this document <br /> <br /> D~'tE:, 12/28/92 TIHE: 15:50:.57 <br /> <br /> BURLEIGH, JAMEG & LECTA 56510946 ~.[I)~NII. AI_ <br />S~TUS ADDRESS: CONSTRUCTION TYPE OCCUPANC~ <br /> <br />PO BDX 181(2 <br />SALEM 97395 <br />PHONE: 393,.,879D <br /> <br />SITE NUIiSER: 92-04;544 <br />,ILJAT[ON: <br /> <br />1.666 AC NO ND <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION NO: 9044620 <br /> <br />CONTRACTON, NO,, <br />SURLEI(;~H, 3AMES & LECI'A <br />PO BOX 18.1.02 <br />SAt. EH 97305 <br />PHONE: 395-8790 <br /> <br />WATER SDPPLY: PW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: 79'--1909 <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES; <br />SEF¥'IC ~ANK RUHPED: <br />PREVIOUS NO, BEBROOMS; <br /> <br /> ITEM (~UANTII'Y AMOUNT <br /> STANDARD 9N,.,SITE SYSTEM l $21D,D9 <br /> <br /> TO/AL ~SSESSED FEES $2:LO_OD <br /> PREVIOUS RECEIPTS SO_OD <br /> THIS RECEIPT $2]0,,00 <br /> <br />  E DUE SD- O0 <br /> RATE{E: BURLEIGH, JANES & LECTA RECEIPT NO: 461f0 <br /> RECEIVED BY: 0M2 .......................................................... TYPE: CK CHECK l~: 5067 <br /> SEE ATTACHED DOCUMENT FOR REQUIREMENTS OF ON-SITE SEWAGE SYSTEM_ <br /> <br />* THIS IS NOT ~ PERMIT. THIS ~PPLIC~TION MUST 60 THROUGH ~ REVIEN PROCESS NMERE THE <br />FOLLOWING MUSl' BE COMPLETED. IT IS THE RESPONSIBILITY. OF TBE ~PPLIOANT 10 ASSDRE INA( <br />ALL NECESSARY INFORMATION H~S BEEN PROVIDED, <br /> <br /> OFFICE COPY <br />FORM # MC 15.56 REV. 4/90 <br /> <br /> <br />