Laserfiche WebLink
Application for Onsite For City Use Only: Date Stamp: <br /> • Wastewater Treatment System City of <br /> Date Received FEVEC <br /> \�// EV <br /> MARION COUNTY PUBLIC WORKS Received by 9 v {.1 <br /> f <br /> BUILDING INSPECTION DIVISION Zoning by ® 29 <br /> 5155 Silverton Rd NE Fee MAR2019 <br /> Salem OR 97305 MA9::110N COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildindnspection Activity <br /> EZEIRESPEEEWINIREFEEIPEMEMEN*Rf§l'erlYA*401j1#.0*(5112!!!!1.2.1!!;f2tginEVE!!!!!22:.!:;:-:'!iniTgliiTY222122012,!!!,2121 <br /> Sheila Lemons 21625 Butteville Rd NE Aurora, OR 97002 503-383-8155 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Le`al Pro a Desch tion <br /> 4 dd 041W08 00400 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 21625 Butteville Rd NE Aurora OR 97002 <br /> Property Address City State Zip Code <br /> bet on 1-3 Norm from Jaiem. lake exit zr a,tum len on tnien r o OII exit. 1 urn r ignt on uuueviiie <br /> Directions to Property: Ga <br /> i er C E ustmg acil>tyE/Propos4040ity/Water3lnforma40:41 w <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ®Single Family Residence © Single Family Residence ['Public <br /> 3 bdrm 4 bdrm Name <br /> Number of Bedrooms Number of Bedrooms ] Private WELL <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ',r, D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit Au horization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement .t 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) <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 /> Richard Adams .503-708-5244 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> . 2000 SW 1st.Ave. Suite 420, Portland OR 97201 <br /> Applicant's Mailing Address <br /> 3/28/2019 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 2 Authorized Representative 0 Authorization to Apply form Attached <br />