Laserfiche WebLink
9L1..mitgtai.:1 <br /> .. . Application for Onsite <br /> - — _ .; Wastewater Treatment System <br /> 11111 MARION COUNTY PUBLIC WORKS AU6 20 2024 <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildindnsoection <br /> A Ptoperty Ownerinformatioa <br /> 1 4oS-c�-vNLScs.J 1 9 S1LvF72 ��t.l-s 02- t <br /> Name Mailing Address <br /> glL\ 2 X (De_ 9q3 81 563-204 .3 LeS•a <br /> City,State,and Zip (Area Code)Phone# <br /> B.LegalP.opertyDescription . . , <br /> 2c)Rq SIDI Viz c .-5 cot 1J cg(Lvt 15 ) p TL c4' 3SI <br /> Property Address City State Zip Code <br /> Parcel# Tax Lot Acreage or Lot Size _ . <br /> • <br /> Directions to Property: ' <br /> C...ExistingFacilityIProposed Facility!,WaterBifarmation. _ <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> ___4 <br /> Name . <br /> Number o Bedrooms Number of Brooms Numbereti of Employees/ Sating of Employees/ <br /> 44 pri <br /> Well Spring,Shared <br /> D Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit 18Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement a Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ 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 /> Akl +C rZSs-f\) (cs 3) 2 C49. -3Cu SZ_ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> ALV<DND'z7T-4-5, Zi.A.-D ste..."3vu�1D-e50M <br /> 2.cr39 SfLv�z_ -F-6.t,c.S D2 N SILVFrc a':1 2 q'p.3r <br /> Applicant' ailing Address Email: <br /> 1 2 0/ `Z-0'z5-4 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner 0 Authorized Representative(form attached) <br /> G:\BIJILDING INSPECTIONVORMS\SEPTIC\S-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,622,6/23 <br />