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MARION COUNTY BUILI~ING INSPECTION <br />SENATOR BLDG! NO. 225 <br />220 HIGH STRi~ET NE <br /> SALEM, OREGO~N 97301 <br /> PHONE; 588-~1'47' ! 8:00 - 4:$0 <br /> 24 HOUR CODE-A~PHONE: 588-7904 <br /> / <br /> <br />I have read ~ agree to the tetms:s~ied On the rever~e ~ide of <br /> <br />I4633 EHL,EN RD <br /> <br />SIGNATURE OF APPLICANT ......................................... <br /> <br />'-- T E"~"sT'~ Fo ~i ' W ~,'~: ........................ 66b~i~V, .... <br /> <br />PHONE: . . ' ,.. <br /> <br />4 <br /> <br />WIDTH: ~EPl'H! AREA: <br /> ,1, 2,5 426 5~25~ i <br /> <br /> TYPF.,~ ON-'S'rTE ~'EWA~E , , ~ <br /> PERI'lIT O~t APPLICATION NO: '~2~2 '.' <br /> C9~ TRACTOR, NO, <br /> <br /> 'F. <br /> <br /> STANOAR~ ON-S~TE <br /> <br />V~LU~TION= <br /> <br />~A~ER $UPPLY: <br /> EST HOLES READY: <br />SITE EVaLUaTION HUM~ER: <br />EXISTING TANK SIZE: <br />EXZSTING <br />SF.PTIC T~NK PUMPED: <br /> <br /> .~; <br /> · '..';", ,. GUANTI~Y AflOt}N-i' <br /> ...:f <br /> <br /> PAYEE: <br /> <br /> Z~ <br /> <br />9~'v/"/S~,,,h~RKS: $~ P SYST~H ~,,,,,,. ~,,~ ~; .... <br /> <br />TYPE: CHECK %: 0 <br /> ITS DATE. <br /> <br />IF <br /> <br />FORM # M~ 15-5~ R~V, 4zv~ OF FICJ~ COPY <br /> <br /> <br />