Laserfiche WebLink
iti ,6_, . <br /> e, ,, z,?iy„!440,/ <br /> Application for Onsite f0 <br /> , YY For City Use Only: Stam p---- <br /> ,.,0440,„„, '�"' <br /> %%:�� Wastewater Treatment System City of M <br /> 1111111 Date ReceivedTo c7)1 <br /> 2. nn <br /> MARION COUNTY PUBLIC WORKS Received by TH <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee 4a <br /> Salem OR 97305 ro Cu <br /> (503)588-5147 Fax(503)588-7948 Receipt# 6 z :� <br /> www.co.marion.or.us/PW/Buildinenspection Activity# <br /> A.IiropertY Owner Information <br /> Matthew Stewart "( Keub er Road S Salem,Oregon 97302 (503)931-5768 <br /> Name ailing 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 /> Same as above <br /> Property Address City State Zip Code <br /> Directions to Property: I-5 to Keubler interchange,right to property <br /> C Existing Facility/Proposed Facility/Water Info rmation. _ _ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> XSingle Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> 0 Other ❑ Other Well,Spring,Shared <br /> D.;.Type of Application.. .:_. <br /> El Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor if Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ►:1 Record Review ❑ Temporary Housing • <br /> El Major El Minor ❑ Other ❑ 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 /> Norman Bickell (503)510-1742 None <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number _ <br /> DEQ Lic.# (if applicable) <br /> 2/2232- 42°d Avenue SE #771 Salem,Oregon 97317 <br /> I'wl `'I f5 /i9 _N/A <br /> Signature Date: _ <br /> CCB# (if applicable) <br /> Applicant is the 0 Owner El Authorized Representative ❑Authorization to Apply form Attached <br />