Laserfiche WebLink
aa0 ie-(4 .-- ,i444 7- <br /> Application for Onsite For City Use Only: Date Stamp: <br /> : ;` c Wastewater Treatment System City of <br /> Date Received <br /> 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 /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A.Property Owner Information _ <br /> (acv► QuL1 ei.vt R2 31-4e CQ Z!a & f/SenAtAiiii, CW_ kt7O 5G1-Zai-6132 <br /> Namp Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description _ <br /> Az vi!A 04 0-12e-ti i-7u 0 ue-ti /1 I <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 33tjo) ro w wok_ S &Lets, 0-K 61:736S— <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> - <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence igi Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ria Private coot <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 /> ID 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 /> 5a.dtz,. 1,- l .r.w, Seth- 7L 4-"Wt.! A sus <br /> Applic is Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> V()& ( S ,2v 0)2 '?71 I1 <br /> Applicant's Mailing Address 1 rr <br /> Si a ,--- Date: CCB# (if applicable) <br /> Applicant is the❑Owner )Authorized Representative Authorization to Apply form Attached <br />