Laserfiche WebLink
• <br /> 55S -2I - 0 I13q S- A-UTH <br /> Atiiiks.,, Application for Onsite For City Use Only: Date t mp: <br /> —r� Wastewater Treatment System City of I-3) ECEOVED <br /> ...._ <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by NOV 1 2021 <br /> 1 BUILDING INSPECTION DIVISION Zoning by _ <br /> 5155 Riverton Rd NE <br /> Salem OR 97305 Fee MAR ON COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> A.Property Owner Information <br /> Michael Hawes 4615 Spruce St Bellaire, TX 77401 832-778-7033 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> 084E32BD B. Legal Property Description 01500 1 acre <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 35414 Francis St SE Lyons OR 97358 <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 /> JSingle Family Residence WI Single Family Residence ['Public <br /> 3 (Fire Burned) 4 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private Well <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ®Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ® Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ❑ Minor El Existing System Evaluation El Personal Hardship <br /> El Alteration Permit El Record Review El Temporary Housing <br /> El Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Dan Williams 503-819-7754 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 2000 SW 1st Ave, Suite 420 Portland, OR 97201 <br /> Applicant's Mailing Address <br /> ILPA Am. 11/15/21 <br /> ,• ure Date: CCB# (if applicable) <br /> Applicant is the El Owner 121 Authorized Representative I Authorization to Apply form Attached <br />