Laserfiche WebLink
SSS - \-\- - 00s'N-to\— C ,CNk-k--- <br /> ,AWN, Application for OnsiteCity y: <br /> For Use Only: <br /> 1-E v %all Stamp: <br /> - City of <br /> 1� <br /> _.._ Wastewater Treatment System Y <br /> Mg <br /> JUL <br /> Date Received JV� 26 20 I <br /> MARION COUNTY PUBLIC WORKS Received by MARION COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by BUIL DING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww.co.marion.or.us/PWBuildingInspection Activity# <br /> w <br /> A.Property Owner Information <br /> kfo1roi!i - C(1ars7l ,J �atf fVs NN IMgc2092-- fir-, _5.,,,121,,,,, 77J s <br /> Name Mailing Address City,State,and 4p (Area Code)Phone# <br /> B Legal Property Description', " <br /> ee iw /7c <br /> Legal Description Tax Lot Acreage or/Lot Size <br /> Subdivision NameLot Block <br /> (p 6 r/ perms 120, AV(1'11/1/1 16 9722.3--- <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 ❑ Single Family Residence DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms u— <br /> /�� I� �Private �� <br /> ❑ Other /I Other Cjo.Nac�^ 2 0 Sei4fS Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 9 Replacing a Dwelling <br /> 9 Repair Permit 0 Permit Transfer 9 The Addition of One or More Bedrooms <br /> ❑ Major 9 Minor 9 Existing System Evaluation 9 Personal Hardship <br /> Alteration PermitRecord Review <br /> 9 0 TemHousing <br /> IX Major El ❑ <br /> Minor 9 Other <br /> Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> -Topa ,z,/,/144-- ,5-03- 9y/— (57T '6 7 y7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> `P' PDX 938 StGuev 't et•V2 973 8 <br /> Applicant's Mailing Address <br /> f`' . 7X6//7 ?2037 <br /> Signature Dat : CCB# (if applicable) <br /> Applicant is the❑Owner 9 Authorized Representative ❑Authorization to Apply form Attached <br /> J <br />