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<br />MARION COUNTY BUILDING INSPECTION -
<br />COMMUNITY DEVELOPMENT CENTER
<br />285 Church at. N£ . Room 132 1)
<br />SoJom, Or<gO" 97301
<br />8:00aDl-4:30¡nn Phon. 5~147 N8V 8
<br />Z4br.ln~:;,~:s588-7904 Ø/ø:?"/ - . ,~
<br />
<br />SITE EVALUATION ANn/OR SEPTIC PERMIT APPLICAjlJf!l'ON COUNT'(
<br />
<br />I. LOCATION OF INSTALLATION lUG INt!>
<br />",,>p,^Yo~", g -" """ Moiling"- Pd, /2,."",,- J,."¡;3 0':"'»....-", pbon,No..r.;<i'3 /£;y- 7t:v
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<br />Job Add.." (J a 1f,,'A," TJ¡.,./¿ (It,¥ T", "... No.
<br />
<br />POR CITY USE ONLY
<br />. Received By: S L
<br />Zon,;ngVal¡~ cÇ;
<br />Dale; ~\ I q.5
<br />
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<br />No. Blnplo""" 2-
<br />"".':..No. 1 ~="'3
<br />..........
<br />W_Supply,
<br />PòvUlCWcll ( ) Spon. ()
<br />comm...;ty WI" ( ) City u;¡--
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<br />B'o'" .J..I.
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<br />Sobdi","" ¡.¡ /':
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<br />!.ole
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<br />Zone ,
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<br />s",lo' I I" 2,. I I" j; ""'g.;c '"
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<br />2, CONTRACTOR INFORMATION
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<br />!mog. Lot
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<br />....-- , Mamn. "d<J<m Ph... No,
<br />e"",,"y Ow."
<br />Ao'". ^.,"tlC"," Ma;¡;.g Md"", ".0"' No.
<br />Coot""", au';"", N""" "Nomb" Mall""A~ "°"0 No.
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<br />3. FEES
<br />
<br />~
<br />
<br />$ ~J () "3:-
<br />
<br />10 "g-
<br />Totnl:3.) () "-"
<br />Te" Holt< Ready:
<br />
<br />.. ,," ¡""Iud, DI!Q Su,""",.. ($00.00'
<br />Site "".lu.Hon, Single Family Dweili.~, fi",t 101................"...........................................................,.' .....................$320.00
<br />~¡:~ ~~:i:¡¡~~: g~;=~~:f~r¿:j~I*!/~~::::::::::::::::::::::::::::::::::::::::{::::::::::::::::::::::::::::::::::j~~:~:;:~~;r~;~~1
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<br />a' lion R,u"l Area Vari."""...........................""",......,.......................",;"..............."",.............",........,.......",.320.00
<br />Constructio" Penni. 0 Commerd.! Major Repill" first 1000 galloos: ;
<br />dM'd aysrem........"....................................-.......",.."",......""""""""""'"""",..........".,......"",....3g2,00-
<br />
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<br />Pr."ure Di"ri~ution Systom....",..........."""..........................:..........,.."",..............,.........".........",..SS3,OO
<br />~:d~f',~: ~~~~ :::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::1::::::::::::::::::::::::: ::::::::::::::::::::::::::::m:~
<br />Soopag< Pil..."."".........,........."............."""",...... ......."........;......,....,.......... ......""".........."......]12.00
<br />s«p:tge Trench.......,.".......,.",..."..",.,.. ..........""",..,............!............... ...............382.00
<br />Sleep Slop<...........,.."",........"..........".......,...""..""",....",......-... ...."".,...................,...."................332.00
<br />Tilo o"",.tonng $y,tcm.."....,..................,..........................................".""",....... ......."...".",.....,.550.00
<br />(on"tueliùn t'ctmit or Cottll\\et<:i<>1 Majot R,<palr. OVOt 1000 gallons:
<br />
<br />k
<br />+$I00IS00gallo,,"
<br />
<br />Con"",.(.o. Pennit Fe< + $251500 gallon,
<br />
<br />Comm""iai PI.. Review
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<br />R<si<!<nÜal ot Ç<>mm"'oi~' I
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<br />N"""ofAppllca",(PleascPrÎnlj: ¡?tJ-1t4r L. L/}YI7~
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<br />Sign"""" of Applie;,nt: . ~r:r""..-, '- >-- ~~ ~ Date, .......£'.S::~- þv 1'5. ~
<br />MC 15-öI ." 8.'95 ~ /
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<br />Tan~ Pump"'" ..
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<br />Pumping certia"con Attached: (Y) (N)
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