Laserfiche WebLink
g 1 -ôSl 05 <br /> _ ,; <br /> 44,04,,.„,, Application for Onsite For City Use Only: Date Stamp: <br /> ...,-......--,---•r- ...F- Wastewater Treatment System City of <br /> Date Received, <br /> 11111111 MARION COUNTY PUBLIC WORKS - Received by <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 /> • <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> • <br /> A Property Owner Information <br /> Yir� VAU y. (oasTr1(.I,ov.-4nc Po Rpt( N IS GCcilic,, O —I o Z} ---. <br /> Name / Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Pro_ er Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot • Block �^� <br /> (/ l 705� Uac,t/-11.: - .�ctv� (Vk S;iuerl-OvN 02 "1. 3 8 i <br /> Property Address City State Zip Code • <br /> Directions to Property: <br /> - = C a xisting Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence 0 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other _ Well, Spring, Shared <br /> ID.Type of A hcatton <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) <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 /> .F6 Com.. <br /> (Ake VG,1 C6 r ct:otn . SO3-8339-33'12 (� <br /> Applic . is Nate—Please Print Legibly Applicant's Phone Number DEQ Lic. if pplic ble) <br /> Pa �- <br /> i c c onbik IL OR 9?.6-3.s S-0-3 $7l 3 <br /> 0490 <br /> Applicant's M. ' Addrs <br /> - ",z/es <br /> 7--2_7.. 20 , g 1 q 7 OOO - <br /> igna e Date: CCB# (if applicable) <br /> • <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:IFORMSISEPTICIS-01 ONSI1'b APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />