Laserfiche WebLink
c9q- 6-tio/61 <br /> &_. _ Application for Onsite For City Use Onfr nee <br /> so—_ ye:,�� <br /> Wastewater Treatment System City of �� �® <br /> r <br /> Date Received <br /> J <br /> MARION COUNTY PUBLIC WORKS ReceivedbReceivedReceivedUL 0 9 202k <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.oraw/PW/Butidlnalnsvection ActivitY# <br /> A.Property Owner Information <br /> Nand Lou Dan;t`eJoil (i-f Lord Lid 5E, 5t ctiokii 6R 9735Z 503-769- 5138 <br /> Mailing Address , City,State,and Zip (Area Code)Phone# <br /> OgIW1SB8 oo6o0 B. <br /> Legal � 1.12. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 688 Icdh 1.11, GkOcn dg /I383 <br /> Property Address <br /> Directions to Property: �Altcak a c c tt) la ll State zip Code <br /> C.Existing Facility I Proposed Facility/Water information <br /> c,.,, ; .g Facility: Proposed Facility: Wales.Supply: W <br /> ElSingle Family Residence ❑ Single Family Residence Public C 1 TY Id4 <br /> 3 Name <br /> Number of Bedrooms Number of Bedroom s 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of AppEcation <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> 0/Repair Permit__ Permit Transfer The Addition of One or More Bedrooms <br /> 0 Major iJ Minor 0 Existing System Evaluation DU Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over rs old) <br /> Stpllc ftud? filtiCemeikk ()till ❑ of — Specify <br /> If the required and attachments are not included with this lice it� application, 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 /> j; ;,( M1 my 50 3-- ?3 2-2 Lf p 1 313 Z-3 <br /> Applicant's Name—Please Print Le gibl Applicant's Phone Number DEQLie.# (if <br /> /777 applicable) <br /> Ac #;ovi Vri ;k7 1Ø' ' /Chit4;(1d7 cc SI i( gq73j7 <br /> Applicants g Ad J <br /> /1" 50 17/ <br /> Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ®Authorized Representative orization to Apply farm Attached <br />