Laserfiche WebLink
, 3-(Db 3 ,C)18 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Min <br /> Date Received FrQ)ECEOVED <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by Ii LI APR 21 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILD NG INSPECTION <br /> www.co.marion.or.us/PW/Buildin2Inspection Activity# <br /> A.Property Owner Information <br /> Pckt- 6Aki NAo OA&WU l -gR"" wnc' Q.0 Sox 0.1S- S4Qa►a, (Xg7137 503-13,)-,237o <br /> Name 1„.,.V4,1 1--is - Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal ro erty Description <br /> LP 3w4. tW 3.1. Acre-S <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Nttt <br /> Subdivision ame Lot Block <br /> ,- ,ar1 Ror-AsPixtt Wc.,2, sk ctuid _' _ q 7137 <br /> Property Address City 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 Tg Single Famiil Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Private voe,t` <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> D.Type of Application <br /> al Site Evaluation ❑ Renewal Permit <br /> ❑Authorization Notice for: <br /> • Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ';,1 'e I.it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 'e' Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 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 <br /> of this application. <br /> PAC:4s c !V Ll/ /ExcLt.0 ,Sr7. — 32q-5`za7 Sgg�6 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant' Mailin Address <br /> �z qA 1 :2 3 /6/// 9 <br /> Si ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner K.Authorized Representative ❑Authorization to Apply form Attached <br />