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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 CODE-A-PHONE: 588-7904
<br />
<br />I am performing work on 8 property I own or ocoupy,
<br />I am a registered builder OR the authorized representative
<br /> of a registered builder.
<br />The work will be performed by a registered builder.
<br />Other
<br />I have read and agree fo the terms stated off the reverse side of
<br />this document·
<br />
<br />SIGNATURE OF APPLICANTz
<br />
<br />OWNER; TAX LOT: ~ CATEGORY:
<br />
<br /> DITTER H]:LL. TRACTS P~RCEL 2
<br />
<br />J('h'li~ff,( ii,!.
<br /> 40'5 JAMES NAY
<br />
<br />/:'HO N:,:: ~:
<br />
<br />[JAI'ER SLiF'PI,.Y," PW
<br />TEST HOLIES READY:
<br />si'rS FVALUATION hIUMBER:
<br />]-S×ISTINF~ TANK SIZE:
<br />I:'"×ZSTING DRAIN F]:EL..O
<br />SEP"f ]C TANK PIJMF'I£D'.'
<br />PREVIOUS ,!0, BIEDROOMS:
<br />
<br /> I'TE bi (:,~UAI'I'f ! T¥
<br />r'i'~'f'F: I;:,V"flt.,U~f"[OH,~ !':]:i:t:~F I._Of ;~.
<br />
<br />TOTAL A,:,ol:oSE9 FEES
<br />F~E ¢IOUS
<br />
<br />,"fi f! ]:".: I~.EC[~: II::'T
<br /> .I .1 I .) BY: CL.
<br /> .............................................................. TYI ,. i¢141:i.C K
<br />:,i;~:-'~'.: hf'FACHEJ) DO_:UMENT FOR REQU'[REMENTS OF ON,SITE SEWAGE: SYSTEM.
<br />
<br /> 'f,, bOl:::':~ hi'. '," ;-I'::,flN'T 3R :I:;¢fI::'I..Y : ,:R rio I,ll' TO ~LIILD ON THZS PARCEl,. ~;"i,,,AJ,II',~.L~,I,t,- , .,:
<br />....... ~' ' Itl, h~._...A .;3~ I. G. ,
<br />· . I I. ..[ [ . . [,: h~ f~: OY~'fh]:Ni~:l RFFORI!i: :~'IU:~_LDING OR S~-t'"T]:C ", '^' '-'" '
<br />
<br /> I,"/:4t.l:l R,: )~ -'"' '~
<br /> · r,:J...!, TU ~NY
<br />,, h': r; ,.., , ~, ~ ,' ~-ir,.:;LD:~N i:OiJliTY BU,~LDiHG OF'FJ:CIAL ,,-
<br />
<br />SAM')
<br />
<br /> OFFICE COPY
<br />FORM # MC 15-56 REV.
<br />
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