Laserfiche WebLink
s) <br /> /g - 00?SSz Ardi- . 0 <br /> r_eApplication for Onsite For City Use Only: "1 m F , le Stam".P: <br /> %; �` Wastewater Treatment System City of r• om' `�� <br /> Date Received <br /> MI MARION COUNTY PUBLIC WORKS Received by 05 <br /> E. pr• ,: <br /> BUILDING INSPECTION DIVISION Zoningby ( i��- <br /> � r; ,,, <br /> 5155 Silverton Rd NE t ; <br /> Salem OR 97305 Fee _ o; 1. .`f- •� <br /> (503)588-5147 Fax(503)588-7948 Receipt# `.a ! ' <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> 99 y� (�{�/�� y^` ,�y��yysyq� (Di <br /> /_�A.Property OwnerlInformationg / �J/y / / 1 c _... _�Jj <br /> A F I V Ill�Y_V-1410 r 1 (Di c iA,��. ' T BA.K.c pa, /"Io b /-jRtw C/l 63 <br /> Name Mailing Address City, State,and Zip i <br /> (pea"Code)Phone# <br /> B.Legal Property Description (�a -to 55 - Q 7C <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 6L50 (41,vF_112.0Atg. 12o 1. S in2 1'73O2- <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence p.Single Family Residence OPublic <br /> i' .) Name <br /> Number of Bedrooms Numbei of Bedrooms Private t, l4 d l . <br /> ❑ Other 0 Other 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 /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ 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) i <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. t <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 /> i <br /> 6A1ES 157411.35 o/moi 3 ago-7 Li <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applic 's Mailing Address <br /> � J �V 1 <br /> * / Z 4 9 g <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner -„, Representative 0 Authorization to Apply form Attached <br />