Laserfiche WebLink
,, w+ Application for Onsite For City Use Only: D © P <br /> NIYC <br /> — Wastewater Treatment System City of <br /> MIDate Received <br /> MARION COUNTY PUBLIC WORKS <br /> Received y MAR 22 2018c67 <br /> BUILDING INSPECTION DIVISION Zoning by MARE ON COUNTY <br /> 5155 Silverton Rd NEFee BUILDING INSPECTION <br /> Salem OR 97305 _ `I Z <br /> Receipt# l <br /> (503)588-5147 Fax(503)588-7948 p <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A.Property Owner Information <br /> Sett. Sylci.sit 361D S vvite.tot,er D2. SA(( ' aZ 973 Sig 3g75898 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: C3R3 Luft) I Sa,Ce_',.-t c G-12 6`I O6 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ® Single Family Residence ['Public <br /> 5 Name <br /> Number of Bedrooms Number of Bedrooms IS Private we I( <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> El Site Evaluation El Renewal Permit ['Authorization Notice for: <br /> E. Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El Major El 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 purposeur� of this application. <br /> O�^G�e.& Sete- d-/2-td . LLc_ Y503- F7q-cii-tie-f �get6 <br /> AppWcant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 17O acx I2S'Z t S;kry,4—:-, t U✓L 1'73 ir/ <br /> Applicant's Mailin l : 'dress <br /> / ._ � "3-z6 - I& , N.01 &� <br /> ot <br /> Si!•.ture Date: CCB# (if applicable <br /> Applicant is the El Owner ..Authorized Representative . -Authorization to Apply form Attached <br />