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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 ~ registered builder OR ( ) the authorized representative SIGNATURE OF APPLICANT: <br /> of a registered builder, <br /> <br />DATE;: 01/131¢5 TIME: <br /> <br /> 19473 MII,L. CREEK RD <br /> <br /> SITE NUHBER~ <br /> PIt0HE~ N/P VALUATION: <br /> <br />TYPE: 0N-SITE SEWAGE WATER SUPPLY: F'W <br /> TEST HOLES READY: <br />PER~IT OR APPLICATI'OH NO: ~2~6~78~ SITE EVALUATION NUMBER: <br /> EX.[$TIN[; 'rANK SIZE.' 1~88 <br />CONI'RACTOR, NO. EXIBTING DRAIN FIELI) LINES: <br />HENI)ENHALL~ ROBE~I' SEPTIC TANK PUHPE~: <br /> <br />PHONE: N/P <br /> <br />~: ~UANTITY Ai~0UNT <br /> I $185. <br /> <br /> ,.P. AYEE: STO~,IE~ JU~Y <br /> RI{[;.,EIVE]) BY: cl <br /> <br /> SEE A?TACHED I)OCUMENT FgF <br /> <br /> ~ THIS IS NOT A PERMIT.',! <br />FOLLOWING MU~T 9E <br />ALL I,~ECESSARY INFORNA'HON H~ <br /> <br /> ~' ~H REV};IN,J~ ~'Y ~A'[E '~2 '-'~ ~ CITY JURISDICT'[Oh: <br /> .. ............. .,.~,...,.,,~ , BY ...................... <br /> RIXHAt:tJ<S',: ESE PF:' 12--27--94 <br /> <br /> $185.00 <br /> $185.00 <br /> <br /> $(4 ,, 00 <br /> <br />~: RECFIPT NO: 6;~414 <br />::TYPE." CK CHECK ~.. 1411 <br /> <br /> A REVIEW PROCESS WHERE <br />;THE APPLICANT TO A~;~URE THAT <br /> <br />D A T E <br /> <br /> OFFICE COPY <br />FORM # MC 15.56 RgV. 4190 <br /> <br /> <br />