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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH 3TREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 58~7904 <br /> <br />SIGNATURE OF APPLICANT: ............................................. <br /> DA?E: ..................................... <br /> <br /> 627~ SHAW LANE <br />AUHSV)'.LLE OR <br /> <br /> 9IT~ NO. ER: <br /> PHI]NEt 749-255~ VALUATION: <br />'LO~: ...... ?s£Gck? ................... S~'c~iO~7- ............ ]'~6~ ..... ~A~E~ ...... ~ .................. t .............. <br /> <br />m ........ ~ i 1,4~ [ ~ i ,, ~ J Hi1 ........ J <br /> <br />TYPE: ON-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION <br /> <br />COtq,RA(,~OR. ~O. <br />HCCOY,; RONALD <br /> <br />PNONE: 749-255~ <br /> <br />WATER SUPPLY <br />TEST HOLES READY~ <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXiSTIN~ DRAIN FIELD LINES~ <br />SEPTIC TANK PI!MPED; I-2S-91 <br />PREWOUS NO. ~EDROOM~: <br /> <br />ANNUAL EVAL. - I'EMP OR HDSHP MN <br /> <br /> QUANTITY AMOUNT <br /> <br /> TOTAL ASSESSED FEES $90.0~ <br /> PREVIOUS RECEIPTS <br /> 'TH~S RECEIPT <br /> <br /> BY: CL RECEIPT NO~ 58881 <br />............. =================================~_== TYPE: IN CHECK ~: <br /> <br />REMARKS: HDBP <br /> <br />CITY JORISDICTISN~ BY ........... DATE <br /> <br />OFFICE COPY <br /> <br /> <br />