Laserfiche WebLink
5-6-5--21—c0C i%)— lEcmvEn <br /> JUN 30 2021 1g <br /> Application for Onsite For City Use Only: MA.RICat ;NTY <br /> ---- Wastewater Treatment System City of BUILE ING INSPECTION <br /> Date Received <br /> • <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by.. <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# <br /> A.Property Owner Information <br /> 5tu44.00 7 u,(Lr'(r .') 2334 taostwa fitafra R'0 Scs571:r MKS dig 77375 Ida-d 7 3--slits- <br /> 1 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ir <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 2 33i Q_.d.obtic.ED 0 Se o-rrs it4044.5 ea.- 77 3 7 S <br /> Property Address r City State Zip Cade <br /> Directions to Property: Afttopc. /I 7.066 co rto 14 1.4655 1.40 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> tplingle Family Residence ❑ Single Family Residence ['Public <br /> i,. Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> Eg►Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> a Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> EL.Major 0 Minor 0 Other 0 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 /> aY Cil1 -2:9)t SysL - 23as <br /> Applicant's Name:::Please Print Legibly Applicant's Phone Number DEQ Lic.It (if applicable) <br /> App iccaant's Mailing Address r <br /> - ---- 4 - ! '- z - -t . .gb.S <br /> Sign Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />