Laserfiche WebLink
a5_ bAbt--i,D 56 <br /> ,, Application for Onsite a 3- \ b 34 \ "T <br /> Date Stamp <br /> -- : Wastewater Treatment System <br /> MNMARION COUNTY PUBLIC WORKS -11 .ECEOVI ' <br /> BUILDING INSPECTION DIVISION — <br /> 5155 Silverton Rd NE DEC 2 2023 <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildin2lnspection <br /> A.Property Owner Information <br /> 1k0hcka‘k M1WZY - 1 ? 3c, 5u .. '( Sr <br /> Name Mailing Address <br /> 5ckeyvv o- ' 3t ) 5a3 SS- ( L( 120 <br /> City, State, and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 757 3� ;(, rN-..,. P(CL SE C7v `113 i-7 <br /> Property Address City State Zip Code <br /> `IktIWI"## Acreage-or-t tze <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 9 ['PublicName <br /> Number of Bedrooms Number of Bedrooms Number of Employees! Number of Employees/ 'Priva <br /> Seating Seating <br /> SP pring, Shared <br /> D.Type of Application <br /> Igl .. ._.._... <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 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 /> rklLt.aq.y cL,(tr 1w.c.,;1..coti.. <br /> Applicant's Mailing Address Email: <br /> qN( 112 'CI "At 4.0 lZ-1$-23 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑Authorized Representative(form attached) <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />