Laserfiche WebLink
S�1,21.-0 '-'? d C H P(eN(T <br /> Application for Onsite <br /> D E c to 8t npf E \1 <br /> a For City Use Only: \\�`\\//JJ// <br /> Nn: <br /> i Wastewater Treatment System City of <br /> ------to Date Received <br /> MARION COUNTY PUBLIC WORKS Received by - in L 12 2021 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MAR ON COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildinaInspection Activity# <br /> A Property Owner Information <br /> •Cl rt She4 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> m B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 11--170% bi0‘.1nS \Jo J 0-6 S\V'e�r On 2a <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply:` <br /> Single F 'ly Residence 0 Single Family Residence ublicu,`Q�✓ <br /> ci— <br /> Nam <br /> Number`of Bedrooms Number of Bedrooms 114b Private vak <br /> O Other 0 Other Well,Spring,Shared <br /> D_Type ofApplication <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> R Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> g Major ❑ 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 /> * r\ T ❑ 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.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 /> e.,\ ' poSZ 3 =-1L -93u(9) 3�1.a.� <br /> Applicant's Name- Legi ly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Q,0 5bu —11)OrNSW CA- °Li. I. a- <br /> A lic is Mailing Address <br /> --1 I ID- I e , L-N1 Ss <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner "Authorized Representative 0 Authorization to Apply form Attached <br />