Laserfiche WebLink
S <br /> Date Stamp: <br /> Application for Onsite For City Use Only: to r 0032100— EvAL_ <br /> Wastewater Treatment Ci of <br /> Date Received r' <br /> S Stem Received by D <br /> .111 y <br /> Zoning by MAY 0 6 2019 <br /> Marion County Public Works Fee <br /> Phone: 503)588-5147 Building Inspection Division <br /> ( 555 NE Court St.,Ste.2260 Receipt# MARION COUNTY <br /> Fax: (503)588-7948 [WILDING INSPECTION <br /> www.co.marion.or.us PO Box 14500 <br /> Salem,OR 97309-5036 Activity# <br /> A. Property Owner Information <br /> 'N % ‘d Jcll A Lc Z . a.i ©2. q73.15— ,1673 97/ /S 77 <br /> Name Mailing Address Phone Number <br /> B. Legal Property Description <br /> Y, 7Z- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address: /.5‹...7Z-`l « le r� e tti <Al:. G) 7J 3 <br /> Address City / State Zip Code <br /> Directions to Property: ,�h ititto/ ZTif Pet)/ /4c ex,-./- 0-,1..s!)- /Duff e?..-1-e?..-1- Ci�aifip <br /> ch(01%/ /f a2!' p pie- <br /> / C. Existing Facility /Proposed Facility / Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑ Single Family Residence firSingle Family Residence 0 Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms IL Private WGl <br /> O Other ❑ Other Well,Spring,Shared <br /> D. Type of Application <br /> Site Evaluation ❑ Renewal Permit 0 Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Personal Hardship <br /> ❑ Major 0 Minor 0 Existing System Evaluation ❑ Temporary Housing <br /> O Alteration Permit ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major 0 Minor ❑ Other 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 /> S-- `-/9 <br /> - ignaturetuDate // /�� <br /> /"'S. /— 7/4016t4/ 503 9? 7 -/577 1I/g.Co3 G�d`,A,/(OM <br /> Applicant's Name–Please Print Legibly Applicant's Phone Number' Applicant's E-m ddress <br /> Applicant's Mailing Address <br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> 5.03 3/05 <br />