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FOR CITY USE ONLY <br />R~ceiwd By: ~ ~- <br /> <br /> MARION COUNTY BUILDING INSPECTIO~ <br /> '2A~ Q'humh .~lt. NIl - RoOm 132 ~ <br /> $alean, Oregon 97301 [~ <br /> <br />SITE EVALUATION AND/OR SEPTIC PERMIT APPLICA <br /> <br />LOCATION OF INSTALLATION <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />~!~toAR~Oiq COUNI'{ <br /> il'lG IlqSPE0]'~0lq <br /> <br />No. lgmptoy~ <br /> <br /> 3. FEES <br /> <br /> ~app ag Fill $v$ ~m .................................................................................................. <br /> <br /> G ay Wa ~ D s~sa Sump <br /> <br /> ~ction Pe~it ~ CO--ertl Major R~ie, ov~ 1~ ~l~s; <br /> ~mm~i~ Plan ~vi~ Con.orlon ~it ~0~ + $25/$~ gallons <br /> <br /> ........................................................................ 133.~ + $~/5~ gallons <br /> <br /> ........................................................................... 122.~ <br /> <br /> Pumper Truck las~fion. ~ Veho~. ........ ............................................. : ...................................... I~.~ <br /> <br />S~gnature of Applicant: ~. -' ~.~: ~ ~ Tank Pum~: <br /> Pampi~g CeMCieatloo Attached: <br /> <br /> <br />