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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: S8~-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I I am a registered builder OR ( i the au horized reprelentative <br /> <br />LOT; <br /> <br />E, UBLiM[TY <br /> <br />~TAYT~, OR <br />~E: 76~-1424 sITE Nu~ER: 92-0389~ <br /> VA~UAT <br /> <br /> ~ . . , 5 ' , ,,2.&....; ................. ~.,,: .................,1~.. ,j .............. ~ 4~ <br /> 3.87 AC : NO: NO <br /> <br />TYPE; ON-~ITE SE~E HATER ~PP~Y: <br /> <br />PEF,~i'F OR APPLiCA'FION NO: 9040059 <br /> <br />TEST HOLE~5 READY~ <br />SiTE EVALUATION NUFEgER: THE RANC.~t <br />EX1STING TANK SIZE: <br />EXIS'r~[NG DRAIN FIELD LINE.~: <br />SEPTIC TANK PUMPED: <br />PREVIOJ~ NO~ IDffDROOFIs: <br /> <br />CONTRACTOR, NO. <br />N ~L,%f~N , KATH L P.,;EN <br />PO 366 <br /> <br />4 <br /> <br /> S'IAYTON, OR 9'/383 <br /> PHONE; 769-~ a, 24 <br /> <br /> iTEm ~ ~ ~mT] TY ~N'f <br /> TOTAL ~E~EO P'E~ $2~0.0u <br /> PR~Vi~ RECEIPT3 $0. O0 <br /> THj$ RECEJ PT $210.00 <br /> <br /> PAYEE: NELl, KA'FHLE~ R~SEiPI' <br /> R~EIVEO ~Y; CL TYPE.: CK ~CI( g: 3797 <br /> <br />.............. ....................................... <br />m THIS IS NOT APE~IT. THIS APPEI~TI~ ~ST ~ TH~ A ~i~ P~ ~ERE THE <br />FOLL~iNG ~ST BE ~LETED. iT 15 THE R~iBiLITY OF THE APPLI~T TO ~RE THAT <br />ALL NEC~ ]NPO~TI~ H~ <br /> <br />C~,TY JURISDICTION: 8Y .................. DA'IE ........................ <br /> <br />OFFICE COPY <br /> <br /> <br />