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I <br />/ <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO, 225 <br /> 220 HIGH STREET NE <br /> SAL~FM' OREGON 97301 <br /> PHONE: 588-5147 8:00 - 4:30 <br /> ~" 24 HOUR CODE-A-PRONE: 588-7904 <br /> ~ // _ <br /> ~r <br />I am ~ register~dm r builder OR the authorized representative SIGNATURE OF APPL]CANT~~ <br />ia De forming work on a property l own o occupy, <br /> <br />~l~r~r~med by a registered builder. <br /> I have read and agree to the terms stated on the reverse side of DAT~; <br /> this document, <br /> <br /> SAME ~ ,' <br /> SITE NUHBER: <br />' PHONE: ; VALUATION: <br /> <br /> ;TOWNSHIP: i RANGE; ZONE: i MAP; <br /> ~ ~ ................. ~._3z 8C_ ......... £__J~_~ J___Np_ <br /> <br />TYPE: ON-SITE SE~A~E <br /> <br />PERMIT OR APPLICATION NO: <br /> <br />?049595 <br /> <br /> .... <br /> STANDARD ON-SITE SYSTEM <br /> <br /> $255. <br /> <br /> PAYEE: HAEVERNICK~ KEN B 51755 <br /> <br /> SEE ATTACHED DOCUMENT FOR,REQUIREMENTS Or <br /> <br /> ~ THIS ~S NOT A PERMIT. THIS APPLICATION HUST ~ THROU~H A EE~IE~ FRflCE~S WHERE THE <br />FOLLOWING 5UST BE COMPLETED. IT IS THE ~ESPONS~BILITY OF THE APPLICANT TO ASSURE THAT <br />ALL NECESSARY INFOEHATION HAS BEEN PROVIDED. <br /> <br />CITY JURISDICTION: BY .......... DAI'E .............. <br /> <br />FORM # MC 1~.66 REV. 4~0 0 F FICE COPY <br /> <br /> <br />