Laserfiche WebLink
EXPIR! "D 03 I -DDalI� <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ---_ � Wastewater Treatment System City of �- `\f <br /> Date Received ,�?7 !'/ <br /> MARIFE <br /> ON COUNTY PUBLIC WORKS Received by ! I <br /> BUILDING INSPECTION DIVISION Zoning by <br /> MAR 16 2021 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 � � COUNTYON <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildinaInspection Activity# <br /> Wit,,:_.: ,1,==, _,.. ,_.:.. . ................---_.:..__:. ...:_-_„:.t_.:z._:......._.. .:. _::::-._::::::..___._-_-= <br /> - :'___.,..,�! .. . _ .:........:.:.: .:._.:...-�R...,,�,:r_....:__.,:.�:_._,..: : e _e Infi'ormatzon �: -- -__-----_- _ --- --- - ----- <br /> - _ s .:� :'..:. ,.... _,.:......_ _�_ ,11."�"rp . Own. r ::...:.::!!:.:.------=_ -- -- - <br /> LJa r‘ e y 44 41�h r ok2.qiesSa 9-1011-1 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> Legal Description..-.._.. Tax Lot Acreage or Lot Size <br /> S division Name Lot Block <br /> 01“\CO t K \--y'l v.s (\_,\ -fl ( CA1) <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> iiialaijrailljaairtitailijliattatkggKiaatiaftggilWNWMPBEIEIEEBeigtegBell <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ESingle Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms I '[Private <br /> ❑ Other Other .mad . Well, ring,Shared <br /> g a of:A licatlorl,.::-.. .,, _ ..: _= - <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> Alteration Pe ' ❑ 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 /> cb ��X \-\Lk9-3 ktOk d 0c C=rleta_ <br /> Applicant' . g Addr- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />