Laserfiche WebLink
gi-t-ez yroz,43-4-0-17,„, <br /> Application for Onsite RECEIV mp: <br /> -_ Wastewater Treatment System <br /> MAY 2 3 2024 <br /> ` MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton.Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildineInsnection <br /> A.._Property Owner information <br /> J 1n,llvo cv rri e, M0-dc, - ' _3 7 4 W‘..Ge,hp, A/1 <br /> Name Mailing Address <br /> ._ -1G,i2 /. 97 <br /> 3D_3 <br /> City,State,and Zip (Area Code)Phone# <br /> B:Legal Property Description <br /> 1(3 7C G�/ac o n.e6, )Z< //1 �h 04- q' 73o 3 <br /> Property Address City State Zip Code <br /> .53 q lSSo 0/1-00 /ice /, 259 ((9.9/ - <br /> Parcel# / Tax Lot Acreage or L tSoSize <br /> g _ .. . <br /> Directions to Property: - <br /> C Existing Facility%Proposed".Facilrtg/'.WaterInformation: . . <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Wa • Supply: <br /> !•4'"blic <br /> Name - <br /> Number edrooms Numbe f Bedrooms Number of Employees/ Number of Employees/ <br /> Seating Seating <br /> Well pring,Shared <br /> D.TYPe of Apphcation El Site Evaluation ❑ Renewal Permit n horization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement .0 Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El 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 /> Applicant's Mailing Address Email: <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 />