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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 2';'5 <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 a property I own or occupy. <br /> ) am a registered builder OR ( the authorized representative SIGNATURE OF APPLICANT: <br /> of a registered builder. <br /> The work will be performed by a registered builder, <br /> Other <br /> I have read and agree to fhe terms stated on the reverse side of DATE: <br /> <br /> t CONSTRUCTIO N TYPE; I 0CC0~ANCY: <br /> 175 DE~0;I'.T ~VE 65~¢~d¢~fiq; ~ ~; IOCCU¢~T LOAD: <br /> 6 <br /> <br />: MAILI"~ ADDRESS: <br /> <br /> PO DDX 47~ <br /> DE'FF~OII' OR 97342 SITE N~BER= <br /> I,':'HONE: 854,-;{;~44 <br /> <br />TYPE." ON-SITE SEWAGE WATE;R SUF'PLY: CW <br /> TEST HOLES READY~ <br /> *I,E EVALUATION NUMtUER: <br /> EXISTI~I6 TANK SIZE: <br />(..[)MIRALIOR~ IlO. :~6198 EXISTING DRAIN F'IEL~ L, ti,IE$~ <br />Db~Altq BETHEL & SONS ED., <br />F'O ~)OX 504 PREVIOUS NO. BEDROOMS: <br /> <br />'FURNER~ <br />PHONE.' 74~-.-2~43 <br /> <br /> ITEM <br /> <br /> PAYEE: DWAIN BETHEL & 'SOblS <br /> /.RECE:[VED BY,',' CL :.' <br /> <br /> SEE ATTACHEI) DOCUMENT <br /> <br /> ~ THiS IS NOT A PER~IT; <br />ALL. f4ECESSAF~Y :[i,)F'O~} <br /> <br />FEES <br />FS <br /> <br />QUAI,ITITY AMOUNT <br /> 1 $280.00 <br /> <br />To <br />INVOICE NG: 63i~ 5:;;~ <br /> <br />TYPE: IN CHECK ,!~: ~. <br />Ys"rEM. <br /> <br /> REVIEW PROCESS WHERE THE <br /> APPLICANT 'TO Ai~.t.J ..... THAT <br /> <br />..... t,-L, FO ~l(.'!-':T' '[dI'i?.l OFI SITE Fp.E (~,OI,I'¢E:F~E~A'?']:/:)t,I DN ,.. J ?, I)E',i],.IS G i ~ <br /> <br /> OFFICE COPY <br />FORM # MC 15-56 REV, 4/90 <br /> <br /> <br />