Laserfiche WebLink
aa- db tS.\a <br /> ,,.. Application for Onsite For City Use Only: Darr stamp_ <br /> Wastewater Treatment System City of <br /> Date Received <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 /> www.co.mariun.or.srs/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> 0 -t. eitt pa r? S.3Z Si/t.. . r, g7.161 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address &gra ititA 5 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 Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms g Private lAktf <br /> Er Other Ceaktottrvese.I ® Other Ctiwt►Ntc+461 Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> [J Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> Repair Permit ❑ Permit.Transfer 0 The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ .Record Review El Temporary Housing <br /> ❑ Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> je Id t +C t _ G144,te'Y Specify <br /> wcJ" <br /> If the required fee and attachments are not included with this app r nconrplete. <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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 <br /> Applicant's "lin ess <br /> q 6-2 2-- 201683 <br /> Si ure Date: CCB# (if applicable) <br /> Applicant is the 0 Owner leAuthorized Representative Authorization.to Apply form Attached <br />