Laserfiche WebLink
... <br /> . ... <br /> Application for Onsite Date Stamp: <br /> Wastewater Treatment System <br /> :: -------,-_,.-,-,---, : <br /> :: - ••• ,, <br /> 1111111 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 /> *iiiiiCtiiiiiiiiioliiiiiiiii#Wiltiiiliiin . <br /> A.Property Owner Information <br /> 0\\C2L4 \i' 5C7 t5 CA-CA.\\--Ct_ Ci.._a. <br /> . <br /> Mailing Address <br /> - <br /> . - <br /> WOO_C) A Y\ 0 ck glalk Ci)Cfb • .217,- $`1API.. <br /> City,--Stite;Wiiir Zip . - --. - (Area Code)Phone# <br /> B.Legal Property Description <br /> \ _5C 9S- 1`101.4k1,10%; ik.c.) .Wo ufocib vk OR ctiorli, <br /> Piiiiiiify--A-ddiesi --- ----------- - ' . City 'State -- Zip Code - <br /> . . _ _ _ -__ . .:.. -..___ - 0 51:w tic)t-73 oo 1-730c, 1.7.0 „, . _ ..__ .._ ,. <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: _ .. _ .. _ . <br /> ... .. ••• <br /> - ,..:- ...,_...._, , ...-- ___ ..... ... <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> SNaine <br /> 'Number of Bedrooms' .Niitaber of Bedrooms IsNatibi*0tE.O.Ores1 IlPixftrtIfEnVIR.$* ni0 Private .Wekk, _ ..- <br /> viS"Caliiit: i '-Setitink <br /> Well,Spring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation 0 Renewal Permit 0.- ifitittiiiiiNotice for: <br /> 0 Construction Permit 0 Permit Reinstatement r•-.13.Replacing a Dwelling <br /> is Repair Permit 0 Permit Transfer 13', <br /> The Addition of One or More Bedrooms <br /> al Major 0 Minor E Existing System Evaluation OPersonal Hardship <br /> 0 Alteration Permit 0 Record Review -.0i Temporary Housing <br /> 0 Major 0 Minor Other . -0 Connecting to an Existing System Never in Use <br /> .:._ <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> , - <br /> If the required fee and attachments are not included this-application, it will be returned to you as incomplete. <br /> Post the Orangetcard aft the_enttance to the property. Flag the test holes,. _ . ._ _ _—,_ ____ <br /> By my signature,I cei-litifit the-infra:nil:ion tliiv-e furnished is correct,and hereby grant Marion County,authorited-agen-rbiffe - - <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application _ <br /> - -- • -- - <br /> Cill 910 "" q.tfti-5 15a_ <br /> ApPlicant's.: nine Please Print Legibly Applicant's Phone Number _ 7.55b <br /> DEQ Lie.#(if applicable) ------'- <br /> .. . . . <br /> CAR.. _ i:latt_ <br /> '.s.lclee .‘,./A. • <br /> Applicant's Mailing-Adifreis- --''' '' ‘- - . . Email: <br /> CCB# (if applicable) <br /> CAUSERMANA.TERASANCHEMAI'PDATA\LOCALNICROSOFTWVINDOWRINETCACHEWONTENT.OUTLOOK\FKIL2DXT\S-01 ONSITE APPL JULY <br /> 2023 REV 623.DOOC Rev 1/15,3/15,6/22,6/73 <br />