Laserfiche WebLink
55- <br /> A lication for Onsite -- DO a <br /> 411441j411,,,,•••.. pp For City Use Only: 0 I Date Stamp: <br /> ,_ City of , ,...� <br /> Wastewater Treatment System �� �� i r <br /> Date Received `> ,J 'I <br /> .1111 J <br /> MARION COUNTY PUBLIC WORKS Received by � i�,1� ,; j iI <br /> BUILDING INSPECTION DIVISION Zoning by � IJ `q y�; (�. `� t _`' <br /> 5155 Silverton Rd NE °`' <br /> Fee <br /> Salem OR 97305 <br /> Receipt# ;\,,,,, ,,h, <br /> :i COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity i ;;_i�f'NG MSPECT1ON <br /> www.co.marion.or.us/PW/BuildingInspection <br /> ----—_ _ A.Property Owner Information <br /> OcLr SWC/Akti-. Pn 80x y5 9 & (.�-e:-.5,bR 97344. (503)q7y-a, ,a, <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> BLegalProperty_Description :•.__ _..._..----._.._:. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> 3 3 Al Ste, ia..rn 14W 0--reAs t#3r� 973 1116 <br /> Property Address { City,/_ / State Zip Code <br /> Directions to Property: ®3 vw/e,s Fes/ D� �-�Z,+ -58 f iii. Ck eck 2,73-CY/kt Veda Le 445.icie. <br />. C.Existing Facility/Proposed Facility/Water Information <br /> Exiting Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ,� -�Single Family Residence ['Public <br /> 3 SFD -buir n-e Z in 1) Name <br /> Number of Bedrooms Number of Bedrooms jg Private <br /> ❑ Other --__ –0 Other Well, -pring, Shared <br /> - --D-..Type of Application. ..: <br /> ❑ Site Evaluation ❑ Renewal Permit gAuthorization Notice for: <br /> 0 Construction Permit ❑ Permit Reinstatement . f Replacing a Dwelling • <br /> A. Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major jz Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ 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 /> James Wccdker - (5,017979-.V q 2g/ <br /> Applicant's Name–Please Print Legibly Applicant's Phone Number =DEQ Lic.# (if applicable)– <br /> pelts on <br /> . cocn re, <br /> 'a box L/G &' 5 of g73q6 <br /> A.plicant's Mailing Address <br /> ir .-- al,42,-L______ 3///aow • <br /> f'ii.ature Date: CCB# (if applicable) <br /> f . <br /> Applicant is they Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMSISEPTIC\S-01 ONSJ h ADPL SEPT 2018.DOCX Rev 1/15,3/18 <br />