Laserfiche WebLink
ZZ-0o7 7P T- <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by DrEIC-E,[1W15, - <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee AUG 18 2022 <br /> Salem OR 97305 <br /> (503)588-5147 Fag(503)588-7948 Receipt# , <br /> Activity# I!IARIOIN COUNTY <br /> www.co.naarion.or.us/PW/BuildingInsuection 91 iLDING INSPECTION <br /> A Property Owner information , . .._. <br /> Name Mailing Address City,State,and Zip <br /> (Area Code)Phone# <br /> B e al roe Descn Pion <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> . \ct 0-ert..�rd vocIAA St <br /> Property Address J City State Zip Codeo <br /> Directions to Property: i k re" u,es-!- r,.-�-�, Pe.., 4 u, r t ..let- c4 4- ?D4h4Is- I ere °9-or Ot ' t <br /> A <br /> T f ®+1 e_ tin .4 re..,,,,.. r .l°F ale. rer,� pf d 0 ri: 7 e r4. -Po. 1e4ry <br /> 01.C e ®peg , ikr_g. -4. <br /> G.Esting Facilltyl Proposed Facility I Water Information „ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 4 Single Family Residence ❑Public <br /> 1! Name <br /> Number of Bedrooms Number of Bedrooms ayrivateer li <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> a ype of Apphcation = , ; ` <br /> r <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> gl.Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> O Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Po RoK spat Tharter oR q7 39 . <br /> Applicant's Mailing Address <br /> A eg , adha e46W/2 liy5g1 <br /> Signature - " Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />