Laserfiche WebLink
••446,14 ,:, _ Application for Onsite For City Use Only: Date : <br /> imiWastewater Treatment System City of NEC -g, -WE7 <br /> Date ReceivedMARION COUNTY PUBLIC WORKS Received by — <br /> BUILDING INSPECTION DIVISION Zoning by OCT 05 2023 <br /> 5155 Siiverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588 5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.orats/PW/BuildineInsuection Activity# <br /> A.Property Owner Information <br /> Te4n Fredrick L .ik 7657 Rosedgif Lei S. 5g1 ) OR 9730/ 801-431-‘O L. <br /> City,State,and Zip (Area Code)Phone# <br /> Name 2 Mailing Address <br /> V83 28 BcoOfj DO B.Legal Pr" "- I sescription, Of /yic <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 7057 Ro.,ec)qIe I_n S 5d�em oe 77,3a <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> g Facility: Proposed Facility: Water Supply: <br /> L'Single F 'ly Residence 0 Single Family Residence ❑Public <br /> Name / �p <br /> Number Bedrooms Number of Bedrooms Private ON /iEiCAA$deAl6 PRoI u51 r <br /> ❑ Other ❑ Other Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: 1. <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ElThe Addition of One or More Bedrooms <br /> ? ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> • ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> p�❑ Major ❑ Minor ❑ Otheerr^ 0 Connecting to an Existing System Never in Use <br /> E FYI S C TANK ElC �E j 1 - ❑ Other over 5 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 /> Te55 F:Se illifri qii 503-73Z-21/4Y ‘323 <br /> Applicant's Name—Please Print Legit' Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 / 6hYnir LI)y 5E 5'rfi, OR ?f317 <br /> Applicant's ailing Address <br /> /a —ay-=z3 _CD/7/ <br /> S' Date: CCB# (if applicable) . <br /> Applicant is the 0 Owner �orized Representative orization to Apply form Attached <br />