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FOR CITY USE ONLY <br />Received By: __ <br />Zoning Vai'idation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:~0pm Phone 588-5147 <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 />Property Owner I Mailing Address Phone No. <br /> <br />Subdivision v -- ~ (] Lot Block No. Employees <br /> <br />Section Township Range Zone ~ Map Water Supply: <br /> Pdvate Well ( ) Spring ( ) <br />Lot Width Lot Depth Acres Irreg. Lot Comer Community Well ( ) City ( ) <br /> <br />2. CONTRACTOR INFORMATION <br /> <br />3. FEES <br /> <br />Mailing Address Phone No. <br />Mailing Address Phone No. <br /> <br />Mailing Address <br /> <br />+ $100/500 gallons <br /> <br />+ $251500 gallons <br />+ $25/500 gallons <br /> <br />Name of Applicant (Please P~int): ~,7~t~ ~A~W <br /> <br />Test Holes Ready: <br /> <br />Tank Pumped: <br /> <br />Pumping Certification Ailached: (Y) (N) <br /> <br /> <br />