Laserfiche WebLink
, 4 Application for Onsite Date <br /> .�� •��,,,� For City Use Only: 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 /> ww.co.marion.or.us/PWBuildingInspection Activity# <br /> w <br /> A Property Owner Information. <br /> \ o H L co sO-NA-r ,Lo jvr- olz 7s( j.3 .-y37-obr7 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal o e Description .. , <br /> To <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> lc)L/c oat. S4 (ver4-o,.) 0.d2. 9-x3g <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 /> El Single Family Residence ❑ Single Family Residence ®Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a 1;1] R pair 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 /> ❑ Major ❑ 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 /> j,. id5dd 6,64/4164d od II-6 cj ?) F.91- I6 7 .396 0,2 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Po . 4o/ &27 , ode. <br /> Applicant's Mailing Address <br /> 413/ 36-3g1 <br /> i a Date: ( CCB# (if applicable) <br /> Applicant is the❑Owner al-Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONS1'1'h APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />