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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG, NO, 225 <br /> 220 HIGH STREET NIB <br /> SALEM, OREGON 97301 <br /> <br /> PHONE:588-5147 8:00-4:30 ~ i L" E <br /> 24 HOUR CODE-A-PHONE 588-7904 <br /> <br /> I am performing work on a property I own or occupy. <br /> I am 8 registered builder OR ( ) the authorized representative SIGNATURE OF APPUCANT: ............ <br /> of a registered builder. <br /> The WOrK Will ~e performed by a registered builder. <br /> O~her <br /> I have re~d and agree to the terms stated on the revers~Dide of OATE; ................................ <br />tNs document, ~,, ,~"' '~ ~ TAX LOT. <br />.... ~ T-'~ ~?t9'~t"~4 ~ <br />OWNf~. ..' ' ' ~ .(H~:~' <br /> <br /> SZTE NUM~ER: 74-03425 <br />l::'HO N [-'.:.= VA[ .UA T I OM .* <br /> <br />TYPE: OH-SITE SEWAGE <br /> <br />PERHIT OR APPLIC~TION <br /> <br />WATER SUPPLY: cw <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br /> <br />STANDARD <br /> <br />PAYEE~ FU'FURE B <br />RLC, F]:V[,g BY.'. CL <br /> <br />SEE AT'IAI,:NI:?~) ]DO(';UMENT <br /> <br />At. I I~L[ZS,~ARY 1NFORMAT:£ON <br /> <br />PLAN R,r'~V:!:t;W:: ~Y <br /> <br /> EXISTING TANK SIZE. <br /> EXISTING DRAIN FIELD LINES: <br /> <br />~'PREV~['OUS"IqO, BEDROOMS: <br /> <br /> O[JAHTITY AMOUNT <br /> <br /> INVOICE NO: <br /> TYPE: II,l CF.E:CIx <br /> <br />SYSTEM. <br /> <br />FORM # ~¢ 1 ~-[~6 RSV, 4i~ OFFICE COPY <br /> <br /> <br />