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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 OODE-A-PHONE: S88-7904 <br />FILE <br />I ~m a registered builder OR the authorized representative SI~tNATURE OF ARRLI~ANT: .......................................... <br />of a registered builder, <br /> <br />Other <br /> <br /> OWNERI TAX LOT: <br />~ HANN DARRL. ENE i 2-~1897-557 <br />~ ~l~O'~ 'XbO~g; ~{ CONSTRUCTION TYRE: [' OCCUPANCY: <br /> <br /> PO 90X ~S7 <br />~ IDANNA~ OREGON ~73~8 ~ SITE NUMBER: 9~-8~272 <br />; PHONE: 854-3735 <br /> <br />~WIOTH~ ~D E ~TH'. j AREA'. { UNITS: <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION <br /> <br />CONTRACTOR, NO. <br />MANN DARRLENE <br />PO BOX 367 <br />?ANHA~ OREGON 97358 <br />FHONE: 854-3735 <br /> <br />WATER SUPPLY: CW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br />EXISTING fANE SIZE: <br />EXISTING DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS NO. BEDROOMS: <br /> <br /> ITEM QUANTITY AMOUNT <br /> ADDITIONAL SUBSURFACE FEES :1, $75..00 <br /> ADDITIONAL SURCHARGE - S~,BSURFACE 1 $10,.00 <br /> % ~ ~ ~OTAL,,ASSESSED FEES <br /> - %~ "~. , ,' FRE,V~OUS, RECEIgTS, <br /> <br /> RECEIVE~ BY: gL_ .... %___~7_....~ .... ~:z2L>__;.: .... TYPE: CHECK ~: <br /> SEE ATTACHED QOCUMENI POE~EQU~REMENTS"OF ON-SITE SEWAGE 9YSTE~. <br /> * THIS IS NOT A PERHIT. ,~HIS ,APPLI'CAT~ON'HUST ~ THROUGH A REV~E~.P~OCESS WHERE THE <br />FOI,.LOWINC HIlST BE COHPLETE9~ IT IS THE 'RESPONSIBILI-TY OF THE APF'LI[ANT TO AS~ RE THAT <br />ALL NECESSARY INFORMATIOH HAS,~EEH PROV:ID~D, '' <br /> <br />PLAN RE¢IECL BY DATE .................. CITY JURISDICTION: BY .............. ])ATE ................................ <br />REMARKS: SEEPAGE TRENCN/ REPAIR (ba] due) in process shelf HOLD FOR EASr_-':MENT., (NINSi~ <br /> REF'AIR AT THIS TINE) <br /> <br />FORM # MO 'l {[-$6 REV, 4,~30 OF FICE COPY <br /> <br /> <br />