Laserfiche WebLink
Application.for Onsite For City Use Only: Date Stamp; <br /> Wastewater Treatment System city of C 11 V <br /> _ . <br /> Date Received <br /> L.-, D <br /> 1111111- ' <br /> MARION COUNTY PUBLIC WORKS Received by _} <br /> BUILDING INSPECTION DIVISION Zoning by AUG 25 2020 <br /> 5155 Silverton Rd NE Fee MARION" COUNTY <br /> Salem OR 97305 BUILDING iCTIN <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.orms/PW/13uildinglinsnection Activity# <br /> A.Property Owner Information <br /> eIVId clg114 2. '18 (t& i C - 5E G(Ot 61/30‘, OR 61/30‘ <br /> Name J Mailing Address City,State,and Zip (Area.Code)Phone# <br /> V k 3k/ 10 070 0 B Legal Property Description 2` 33 <br /> Legal Description / Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> iO745 Oed< ,De 'iE 34'441 die 4773D7 <br /> Property Address ./.3City State Zip Code <br /> Directions to Property: (pc( L t�ptf� 4 S <br /> C.Existing Fa ility/Proposed Facility/Water Information <br /> Exis r .1 Facility: Pro sed.Facility: Water Supply: <br /> ►; gle FamilyResidence Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well pring,Shared <br /> D.Type of Application — <br /> ite Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Rep.lacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> • Major ❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other–Please Specify <br /> If the required fee and attachments are not included with this application, it will be returned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. <br /> By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> re 55 R, e 14 yvi g 503-- 731-2 go/ V Z.3 <br /> Applicant's Name–Please Print Legi Ly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 l er5hnl;r LfiAy 5E flcw,.► M 07317 <br /> Applicant's ailing Address <br /> Dgi2`f 2. 0 .comm <br /> s...:.,: _ Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Autiaorized Representative Authorization Co Apply form Attached <br /> PP <br />