Laserfiche WebLink
-,1),„\-k n(\..L.n's -QF .1-bb 2 LAB <br /> . , Application for Onsite For City Use Only: Date Stam <br /> ;--1..Y Wastewater Treatment SystemUN City of E <br /> (� _ ��j ��-Date Received LS 1l <br /> MARION COUNTY PUBLIC WORKS Received by D,15 ''' <br /> BUILDING INSPECTION DIVISION Zoning by FE. ,4-- i .1 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee NI ' RIdN COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.oram/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> 1 eresa &rver PO. egt8701 Zotilet.s D g133R 503-580-$9R� <br /> Name Mailing Address City,State,and Zip Code)Phone# <br /> B.Le al Property Description '. <br /> �aa�-�esvlll�. ca:s L:5 cit of*AO p' Qfamzn•1)1)-O Ozloo <br /> Legal Description Tax Lot Acrea a or Lot Size <br /> car 5(0 0.i n Pet 121 <br /> Subdivision Name Lot Block <br /> i 11 (..0 tet kal1_ J\vf, Cates ISR 973416 <br /> Property Address City State Zip Code l <br /> Directions to Property: a ..# . ADM i it !,h l /Ir) - I It �T >II <br /> rne+r6 Mi t1 124. 1°11 an ti.) ('E e� 4V0, . Apps /50 +. ern le )-. <br /> + C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Single Family Residence Public 3 OGky <br /> 3 • Name <br /> Number of Bedrooms <br /> Number of Bedrooms <br /> ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Applicatio <br /> IF IR Site Evaluation 0 Renewal Permit ' A_ ,. thoriza <br /> _ hon Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> IR Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major '/iir Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing • • <br /> 0 Major D Minor ?tg Other 54- A nem" t c ❑ Connecting to an Existing System Never in Use <br /> 'en Old SePil C- place (over 5-yrs old) <br /> 1g Other-Please Specify R OVIY1Cl do t►k 4- <br /> r a' i ki <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 /> ef66a iblruefi 503.580. 8991 ,3ACA 66 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P.D. exec, %`iq `ballyis, OR q(133% <br /> Applicant's Mailing Address 1 <br /> -0112.00"- �,ce r Ce1h9 lava I <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 1Xywner 0 Authorized Representative ❑Authorization to Apply form Attached <br />