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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: E88-5147 8:00 - 4:30 <br />HOUR CODE-A-PHONE: 588-7904 <br /> <br />am a teglatered builder OR ( ) the authorized reoresentBtive <br />The wofl< will be Derformed by a rr~g stared bu der, <br /> <br />I have read and agree to the term3 <br /> <br />DATE: ........ <br /> <br />rlI.E, 12:23:14 <br /> <br /> 270 ~ANT[AM AVE -- <br />OE'/'ROi 1' OR...92342 . , <br /> <br />TAX LOT: <br /> <br />................. g022-'1--2-t-0 <br /> <br />, ~OI~'~C? C179: ' "-U~bz '.(~C~UPANT LOAD; <br />DETROIT NO .o. O~ .~o~oo~: <br /> <br />~095 FiR 'TRP.7.E DR ,,.%E ; <br />SALE.~, OR 97301 <br />F:'HONE¢ 364~6251 . Sil'~ NUFSER: 92-01875 <br /> ' , e~o/'~: ....... .'SEbT~O~: ............ ~'bWi, i~l'~ ..... ~ 'h-Ah~,ALUAT' f'ON ::-~-mg*~': <br /> <br /> 997'9'~,; ..... ; ......... ~F · '; .............. ~'~' ' NO ..... <br /> <br />MAP; <br /> <br />TYPE: ON-Slr"f'E ~£WAGE <br /> <br />PEF~4iI' OR APPLiCATIG~N NO.; 40021 <br /> <br />CONTRACTOR, NO. <br /> <br />3095 FIR 'T'R[E OR SE <br />SALEM, OR 9'1301 <br />~HONE: 3~A--626~ <br /> <br /> 1 I" EM <br />~I'I'E EVALUA'F[ON, F'[F~I' LOT <br /> <br />PAYEE: <br />RECEIVED BY: CL <br /> <br />iWATER E~UPPLY: <br /> T~LE, T HOLES' REAOY= YES <br /> ~II'E EYALUATiON NU~ER: <br /> EXISTING TANK <br /> ~)(ISTiNG .DRAIN FIELD <br /> SEPTIC TANK PUMPEDt <br /> pREV[ CU~ NO. <br /> <br />PREVIC~JS RECEIPTS <br />THIf5 RECEi P'r <br /> <br />QUAN'I i 'f'Y AMC~N'[ <br /> 1 $220.00 <br /> <br />$220.00 <br /> $o.00 <br /> <br />BALANCE DUE <br /> <br />INVOICE NO: <br />CHECK <br /> <br /> ....................................... ~ .................. TYPE: <br />SEE ATTACHED DOCUMENT FOR RET~JIREMENT5 OF ON-SiTE ~P:)NAGE SYSTEM. <br /> <br />NOTE: THIS DOES NOT GRANT OR IrC~oLy PER~IIE~Ic~N TO BUILD ON THI:5 PARCEL. PLANNIN~; AND <br />CONSTRUCT.EON pERf, II'TS IVlLIE, T BE OBTAINED BEPORE BUILDING OR SEPTIC [N~STALLATIO/N <br /> <br /> PLAN RE'VIEW: BY ...................... DATE ........................ CiTY JURISDiCTiON.* BY ....................... 0AI'E ................... <br /> R~RKS: SE <br /> <br />OFFICE COPY <br /> <br /> <br />