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-FOR'OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> :~O.~h s-.~ NE <br /> Salem, OR 9~1 <br /> <br /> ~-A-P~e ~7~ <br /> <br />S~TE EVALUA~ON APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />LOCeflon o! Installation <br /> <br />'Cu~nractor Business Nam~ & Number M~lln8 A~s & Phm,~ No, <br />3. SeplIc Information (Ch~ck where applicable) <br /> <br />F~i~ting No- ~moms: 3 <br /> <br />Supply; Well [] Ci[y [] ~.p~ng [] <br /> <br />4. Fee Schedule <br /> <br /> S~ ~v~lu,,,~,.~ F~: <br /> <br /> T~{ Amount Due: <br /> <br />R c~Xdl~ No. <br /> <br />Test Holm Ready: <br /> <br />Will Call When Test Holes Ready: <br /> <br />Signature of Owner or Authorized Agent: <br /> <br />This is a technical report for on-site sewage disposal only end does not grant or <br />imply permission to build on this parcel. PlannMg approval, construction and sspHc <br />permits must first be obtained before bulidlng or septic InstaHatlon begins. <br /> <br /> <br />