Laserfiche WebLink
. 1 2- <br /> Application for Onsite [ [Hwy <br /> DWastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS S P �" 0 Z023 <br /> BUILDING INSPECTION DIVISION MARION CQUN Y <br /> 5155 Silverton Rd NE BUILDING INSPECTIQIy <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinelnspection <br /> A.Property Owner Informatioa, <br /> -77; r /`17 "".6 O%i -iQd/2J <br /> Name Mailing Address <br /> ,u`l�a OK- '7700g- <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description, <br /> l!0 /ua 41- v► OR- 773?2- <br /> Property Address City State Zip Code <br /> 00 X 139 ' <br /> Parcel# 1 Tax Lot Acreage or Lot Size <br /> Directions to Property: lc- S7. i c /t/(c2 ciLey <br /> C.Existing Facility?Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ,Public <br /> �3 Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees! Number of Employees/ ❑ Private <br /> Seating Seating <br /> Well,Spring,Shared <br /> D,Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: • <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Et Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> i,Major ❑ Minor El 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 /> T,t to- i y %K -A v') 5.-o3 q/0--7/?7 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. #(if applicable) <br /> (?7�6 0/yl4 3 nar �2d A/fir:' _1 ®R-- 77002— -1 a 95'1 11,C0N( <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the yl,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 />