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FOR CITY USE ONLY MARION co~u~ryCOUNTYDEvELOPME~BUILDINGc~rmRINSPECTION <br />IReceiv? By:~ ~s Ch~ S~ ~- ~o~ ~3e <br /> S~c~ O~gon 97301 ~ ~ <br />[~ni~ Vflid~on: <br />IDate: ~ hr. Im~n Line 37~27 <br /> FAX ~-79~ <br /> SITE EVALUA~ON AND/OR SE~IC PE~IT ~PLICATION <br /> <br /> 1. LOCA~ON OF INSTALLATION <br /> <br />2. CONTRACTOR INFORMATION <br /> <br /> Contractor BuslncssNam~&Number ,~ ~ ~ ~ ~'~&~ ~p.~_ Mailing Address ~ ~e ,~.~ PhoncNo. ~'~ ~ ~ <br /> <br />3. FEES <br /> <br />Residential or Co--iai: <br /> <br /> ............ 247.00 <br /> <br />+ $100/500 gallons <br /> <br />+ $25/500 gallons <br /> <br />+ $25/500 gallons <br /> <br />Name of Applicant (Please Print): <br />Signature of Applicant: __~Date: <br />MC 15-S1 Rev 8/96 <br /> <br />Receipt: <br /> <br /> Total: <br /> <br />Test Holes Ready: <br /> <br />Tank Pumped: <br /> <br />Pumping C~ification Attached: (Y) (N) <br /> <br /> <br />