Laserfiche WebLink
01-1-15b5L1 12_5 <br /> Application for Onsite Date Sta <br /> RiciEwEB <br /> ; : Wastewater Treatment System <br /> BMMARION COUNTY PUBLIC WORKS JUL 16 2024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A` Property Owner Information .- <br /> 114,41.1< I'Lvvx'i[4-ov►... !b s 3 Ol rim Pk) Soti_tom I ` 7 6 <br /> Name Mailing Addrd'ss <br /> I 51-1" 4-/ 7 7 07/1-L1/573 g7/ 4774 r <br /> City,State,and Zip (Area Code)Phone# <br /> B,VC alPro a Desc tion <br /> �., ._. ._.g...-_ �.p..?'h' < vet? _.. .., .... . ... ,, , . .. .. .. .. . . ... . .... ..._. _.. ,.... J <br /> Property Address - City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> C! xJstmnm Facility/Proposed Facility!Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ �'(I priv - <br /> Seating Seating +` <br /> 9 <br /> D;Type of Application <br /> ng Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> 44 Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> el M3ajr,Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ ExistingSystem Evaluation Personal Hardship <br /> Y ❑ <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 /> Bymysignature,I certify that the information I have <br /> g � fY furnished is correct,and herebygrant Marion County,authorized agent of the <br /> g <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Appl/icantt''s Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> ezt-t ae-4\kovida‘A er s r solioiA._0-iR90117 kival-c- ak,co 4)240 i?,cz <br /> Applicant's Mailing Address Email: <br /> 14(e3)E/14--- <br /> `7-I6- /6S8- <br /> Signature Date: CCB# (if applicable) <br /> HTTPS://MAR IONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONALBREICHCO_MARION_OR_US/DOC UMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23 <br />