Laserfiche WebLink
., �,. Application for Onsite For City Use Only: - nate Sram . <br /> =• ' Wastewater Treatment System City of.--..-._ E C� N <br /> Date ReceivedMIR D <br /> . MARI.ON COUNTY PUBLIC WORKS Received by 1 Loy <br /> BUILDING INSPECTION DIVISION Zoning by MAR-2 6 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MAR ON COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUI rDING�INSPECT <br /> www.co.marion.or.us/PW/Buildinilnsaection Activity# <br /> ION <br /> A.Property Owner information <br /> Agafia Kalugin 10807 Duck Inn Rd SE Brooks, Or 97305 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone li <br /> B.Legal0Property Description S <br /> 11 ` i. 7 cX Fs <br /> Legal Description Tax Lot Acreage or Lot Size <br /> al � Parcel#2, Partition Plat 2017-054 <br /> subdivision Name Lot Block <br /> .7t't-Parr Rd NE Gervias OR 97026 <br /> Property Address City State Zip Code <br /> Directions to Property:Past school, on East side of Parr rd. <br /> C.Existing Facility 1 Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ® Private well <br /> ® OtherChurch 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ T• he Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation 0 P• ersonal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> Ed 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 /> Erin Sharp/E and Z Excavating LLC 971-409-7495 #39104 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 453, Molalla, OR 97038 E mail erineandz@gmail.com <br /> Applicant's Mailing.Address <br /> 3/15/22 #220602 <br /> Signature Date: CCB it (if applicable) <br /> Applicant is the 0 Owner lia Authorized Representative ❑Authorization to Apply form Attached <br />