Laserfiche WebLink
001 -u3L1 633 <br /> Application for Onsite For City Use only: note Stamp: <br /> �3 < :`- City of Wastewater Treatment System R-ECOVE <br /> Date Received <br /> I Ell MARION COUNTY PUBLIC WORKS Received by 04 2021 <br /> BUILDING INSPECTION DIVISION Zoning by MAY <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt 1 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Activity# <br /> www.co.marion.opus/PW/Buildinalnsnection <br /> A.Property Owner Information 3 ' <br /> Yuri10 1/45fut-i 856 814,h{ 5� 'oaalovnz Q1 9707i ° - 0 09 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> N N ' t t 6 753 R f� B.Legal P ojertl Description J 7Legal l5eAcription Tax Lot 0 QQ Acreage orb Lot Size <br /> Subdivision Name rr Lot Block <br /> 9929 Cro5h �da �ood vr� o q,7c7/ <br /> Property Address 1-, !� �1 City r State Zip Code <br /> Directions to Property: w 1 (if ►1 E 1 0oNEs Y''e'rf Ra <br /> .... <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proyfised Facility: Water Supply: <br /> ❑Single Family Residence Single Firily Residence OP"ic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private r. <br /> ❑ Other 0 Other WI+pring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Co 1 traction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ ' pair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> • ajor 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> E Al ation Permit ❑ Record Review 0 Temporary Housing <br /> Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> lithe 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 /> e55 R:Se0 vfri Q 5o3 731-2yo/ ‘323 <br /> Applicant's Name—Please Print Legt Jy Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 ,,- LiA y SE fl 1 , 6/2 (i7317 <br /> Applicant's 'ling Address <br /> 05 d3 �i <br /> Date: CCB (if applicable) <br /> Applicant is the❑Owner Authorized Representative IrlAuthorization to Apply form Attached <br />