Laserfiche WebLink
5Ss-23-vim r �o�—��c, <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received E C <br /> MARION'COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by FEB 28 <br /> 5155 Silverton Rd NE Fee LULJ <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt#Activity# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinglnspection <br /> A.Property Owner.Information: - <br /> L imart; Buy <br /> 6'877Vo//,�yyVewc 5E 'Turner OK ?7,J90Z Jo3-7�9-3S1�. <br /> Name Mailing Addriss City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> k <br /> Subdivision Name Lot Block <br /> N5-877 \Alley View kol St ) ()met OR. 97ty <br /> Property Addrdss City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ►7 Single Family Residence OPublic <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 1g Private We.)I <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 ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> MMajor ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ 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 /> 4-1Y\ela 13e• -S .5a3- 76?- 35I2. <br /> Applicant's Name— ' .e Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 4877 vcilley View Rd SE 1 ornev' ©R c/73 92 <br /> Applicant's Mailing Address <br /> (q..? <br /> Stgna'ure —` ) d Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />