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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 - 4430 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />Other <br /> <br /> L <br />SIGNA'rURE OF APPL CANT: <br /> <br /> I <br /> ;"86~f~ZSf ~i~: ...... ;" 8¢~: j OCCUPAnt LOAD: <br />2(~727 I.'IICH~hY 99E ..... ~ ' <br /> <br /> ................................................................................... <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERNIT OR ~PPLIC~TZON <br /> <br />col,rrR~c'foR~ <br />OREGgN I~'L.O~ER!~ Il,lC., <br /> <br />NATER SUPPLY: F'W <br />TEOT HOLES READY: <br />S]:TE: EV~I,,,UAT~ON NUMBER: <br />EX]:[~T'rN6 TANK <br />EXISTING DRAIN F:[EL.D <br />~EF'TIC TANK PUMPEO;; <br />F','REVZOUS NO. bEDROOHS~ <br /> <br /> I'T'E~ GU¢~NT Z 'I'Y AMCqJN1" <br /> ,:,II) ONSZTE SYS < '8~,~1 ¢AL, 1 <br /> <br /> TOTAL ASSESSED Ft;:,I;:,o <br /> <br /> SI~:;E ATTACHE~J ~)OCUMENT FO~ F:EQU]:REMENI'S OFON-,pr',(T~ SEWAGE c~ys~(;,M. .... <br />.... ," r ~ER~IT. TH~S ~PPLICATIOH MUS~ T ROU6H HU,~T <br />I.,O L. f3W,[IJ(¢ ~:E COHF'LETED,, IT IS TIqE: RESF'gN:St L3: Y OI:, 'f'l.-IE I,,'F'I.:I,C~ <br />ALI., dLCE¢,, A~ :[NFOli~HAT~][~N HAS ]~q~:Ebl FROVZ~E~). <br /> <br />:;fli::HAR <S: f]CHht:Fd.,1, ALP, FF',q"I:: <br /> <br />(.,.t. lY ~UI, .,,,, DJC'rlON,, BY ............................. DATE: .......................... <br /> <br />OFFICE COPY <br /> <br /> <br />