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FOR CITY USE ONLY <br />Received By: _ _ <br /> <br />Zoning Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 295 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00nm-4:30pm Phone 5~8-5147 <br /> 24 hr. Inspection Line 373-4427 <br /> FAX 588-7948 <br /> <br /> SITE EVALUATION AND/OR SEPTIC PERMIT APPLICATION <br />1. LOCATION OF INSTALLATION <br /> <br /> PdvateW¢ll ( ) Spring ( ) <br />Lot Width Lot Depth Acres Irreg. Lot Corner Community Well ( ) City ( ) <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />Mailing Address <br /> <br />Mailing Address <br /> <br />3. FEES <br /> <br />+ $100/500 gallons <br /> <br />$25/500 gallons <br />$25/500 gallons <br /> <br />Name of Applicant (Please Prin0: <br /> <br />Signature of Applicant: <br /> <br />MC 15-S1 Rev 8/96 <br /> <br /> Receipt: Total: <br /> <br /> Test Holes Ready: <br /> Date <br />Dale: Tank Pumped: <br /> Date <br /> <br /> Pumping Ccr tific~aion ARact~d: (Y) (N) <br /> <br /> <br />