Laserfiche WebLink
(95"cnr 01PRI <br /> ,yam•"' Application for Onsite <br /> For City Use Only: Date Stamp: <br /> I = - Wastewater Treatment System city of <br /> NIII Date Received " 7 i,L <br /> MARION COUNTY PUBLIC WORKS Received by `` / ! r 1 ,,-- <br /> BUILDING INSPECTION DIVISION � �` / <br /> Zoning by <br /> Pf <br /> 5155 Silverton Rd NE Fee MAR 0 l- <br /> Salem OR 97305 - <br /> (503)588-5147 Fax(503)588-7948 Receipt# MAR I N COUNTY <br /> WWW.co.manor.ores/PWBuildincinsnection Activity# BUILDIN INSPECTION <br /> A.Property Owner Information' <br /> -414,4 62e� We rM m /.0 5c <br /> SA <br /> Name < Mailing Addresst�ivri0�' ed1-OD-93y/ <br /> /• City,State,and Zip (Area Code)Phone# <br /> QF ,ate, _ B.Legal Property•Description ' <br /> Legal Description /05&oZDA ao .v o3c O PI col <br /> Tax Lot Acreage or Lotsize <br /> Subdivision Name - if, <br /> +, Lot Block <br /> 2 Aug Damesr. O2 <br /> Property Address City q731-1 <br /> Z <br /> Directions to Property: <br /> State Zip Code <br /> • <br /> • C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: <br /> Water Supply: <br /> ['Single Family Residence c fYI Single Family Residence <br /> ®Public Girt or Da rnoz:f <br /> • Number of Bedrooms 7— Name <br /> Number of Bedrooms <br /> 0Private <br /> • <br /> • ❑ Other <br /> 0 Oilier. Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit <br /> 0 Construction PermitDAutheplacingn Notice for: <br /> 0 Permit Reinstatement ❑ Replacing <br /> ❑ Repair. Permit 0 Permit Transfer � g a Dwelling <br /> ❑ Major; 0 Minor 0 Existing System Evaluation Q The Addition Hardship One or More Bedrooms <br /> ❑ Alteration Permit 0 Record Review ❑ Personal <br /> ❑ Major 0 Minor 0 Other 0 Temporary Housing <br /> 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Spccify <br /> If the required fee and attachments are not included with this application,it will be returned to you as incomplete. <br /> Post the oran a card at the entrance to the. roe . Fla -the test holes. <br /> • <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 J • '-- - p petty for the sole purpose of this application. <br /> _ �ivrGL/ Skr"G"1�! - - <br /> 7 - 5° 3) 7m g8c,3c-! <br /> Appucanrs Name—Please Pri it Legibly Applicant's Phone Number <br /> DEQ Lic.# (if applicable) <br /> O. x IISZ ; 9 so <br /> Applic - 's Mailing Add ss <br /> Signa :3-3"�3 /6 5-6& / <br /> Date: <br /> CCB# (if applicable) <br /> Applicant is the 0 Owner <br /> 0 Authorized Representative ❑Authorization to Apply form Attached <br /> Scanned with CamScanner <br />