Laserfiche WebLink
22 -00(S-73— P <br /> Application for Onsite 1 4444 For City Use Only: Date Stamp: <br /> — �c Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by ©ENE <br /> nBUILDING INSPECTION DIVISION Zoning by ' <br /> 5155 Silverton Rd NE Fee L,J <br /> Salem OR 97305 EB 2 2 2022 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# MARION COUNTY <br /> A.Property Owner Information FBUILDING INSOECTIOI <br /> Dr\ \\J‘Q \i kiKtk <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> o 6(-1 GLCr4 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> \ \l js VAII, IN1 :i\r‘ <br /> Property Address Cite 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 Ai Singlely Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private we X\ <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> X Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 44.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 /> ❑ Major El 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 /> 1-s�(.���o,fi ' `tu3 (D3�� ou1so\is <br /> Applicant's Name-Please Print Legibly 3 xApplicant's Phone Number DEQ Lic.# (if applicable) <br /> 'PO -.1)/• --\- c j - Ci. OC a <br /> licant's Mailing Address <br /> Ot 1 RS I OD- LigSS1 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 114 Authorized Representative 0 Authorization to Apply form Attached <br />