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MARION COUNTY BUILDING INSPECTION
<br />SENATOR BLDG. NO. 225
<br />220 H~GH STREET NE
<br /> SALEM, OREGON 97301
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<br /> PHONE: 588~147 8:00 - 4:30
<br />84 HOUR CODE-A-PHONE: 588-7904
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<br />[ am perfo r~ ing work on a property I own ot occupy,
<br />I am a regls{eced builcle¢ OR ( ) the authorized representative
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<br />~IGNATURE OF APPLICANT ......................
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<br /> DALE; .........................
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<br /> OVCiqEn: .DAli_-%-~z~/~/9~'~ ......~' "- .... ~'~ ....... ' ...........
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<br /> ~ L:n,.~:,O., T~> .... ~'~a~'W~: ..................... ~;'~-
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<br /> 1~262 LEVE~H~N ~D ~E ,~ CO~T~C~ C~: "~'~ ................ ~'~[6~6l .... ~
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<br /> F'HONE~ 3~2-497~ ~ VALUAT~ON~ :
<br />' ~ ' _, ~ ................. : ....................... L-~,..
<br /> ;..~0_ ..........~--..NO.~, ............................
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<br />WATE~ SUPPLY: ~W.
<br />TE~T HOLE8 READY~ xes
<br />S~l'E EVALUATZON NUMBS'R: SINOR~orr'""
<br />EX~TING TANK ~IZE=-
<br />E×IST~NG BRAIN ?IELD L:~NES:
<br />@EPTiC TANK PUMPE~:
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<br /> Z ')'EM QUC..NTITY
<br /> STAI'-tDARD Oq~8,fTF SYSTEH 1 ,
<br /> TQT,A..L ASSESSED FEES ~',-'~,' "
<br /> ¢,:.Ju. 00
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<br /> · "t~ht_A,~g~ DUE
<br /> ":'' ' · , 3, ,~.
<br /> F'AYEE',; L:L!,I~,";9~ 'fED "" "'":" ........ :;' "" ": ' RECEIPT N,_"i: 484?6
<br /> F<L"C,E:[V['.'D BY: cT .,':,r-'. -.
<br /> TY, .~ CK CHE,,ill, K ~: 0
<br /> SEE AT'I'ACHEI) I)OC, UHENT FOR RE['qU'I. RE~,I~[¢T8 OF' ON-Ed'T£ SEW~EE ~-"SITM
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<br /> Y¢ T~IS ZSA YALI]) PERi'iii * THIS PER~.ZT ·EXPIRES 3&~ DAYS FR01't IT~ ZSSU£ DATE. IF
<br />I,*ONS'F~{Jt:;'Y'];OJ,~ FAZ[,,$ TO MEET ALL f,'EQLI'.'REHENTS OF ~TATE LAW~ AND HAR~:ON COUNTY ~ ....
<br />ZM,17:, ;', OE'D):MANCES,,. r,h,S? PERMlrT S,HAi_L BEOOHE NULL AND vol]). .,U~.._D~.N,.
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<br />D[1NAI_D IF.,, 9[:OD!.,EY,~ MARIO,kl COUNTY BIr;(.LDIN~ OFFiCrAL /
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<br />ron~ ~ MC ~ 5-,~ ~v, ./oo OF FICE COPY
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