Laserfiche WebLink
• <br /> Application for Onsite- mil <br /> g-gaoe,Sz-L -Pki.Prou --- <br /> = �t' For City Da.: .. ; <br /> Wastewater Treatment System City of <br /> .:',4,-.1*.. Date Received Z U u u <br /> '. ' , MARION COUNTY PUBLIC WORKS Received by Z 0 <br /> • BTi1 DIN 3 INSPECTION DIVISION Zoning by 93 0 <br /> 5155 Silverton Rd i.Ts+ C)Z ea lJ� <br /> Salem OR 97305 Fee jl <br /> (503)588-514.7 Fax(503)588-7948 Receipt if - 0 �•:=}� <br /> www_eo.marion.or.ussPW/Buildinalnspectjoa A ' <br /> ,,-.-y::_•7 ' e4? ... - - -A--Pro a Owner • <br /> - -_ - .- - -- -- -priY _ ..-_- �Infai�on ` :::. -- . _•. <br /> CV i N in. .u%c(Soi09 Le i i s St. 1Ue4---Ver,1 1 17.3 gr/ 50.3 -551-,lo (.7 .. <br /> Name � z <br /> YailinAddress <br /> -- :: .. - -•_- .-- City,State,and Zip (Area Code)Phone <br /> _ <br /> _ ---_ B_`Le�Prr erty D_escrlption :1----"_-;' •.- -- <br /> 6 2-. .P In � S _ - O-+i7 comes <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 959 Te_fdreeam-. 5ce-tks_iii4�( is __ .973 75 <br /> Property Address City State Zip Code <br /> Directions to Property. G,—,d t ice-. 4 '. U - : A 0. c. cI <br /> ._-:: _C. isbnjFa • IPro osedFa '"".%Wer1nfoiinatioa':= :=_ . -=.:: : . - <br /> :.istins Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence iiti Single Family Residence 4Fublic .Cf. p(. ' tj(t " I l S <br /> y N <br /> Number ofBedrooms NumberofBedrooms j] Private - <br /> 0 Other <br /> _ - ❑ Oilier Well,Span„Shared <br /> - <br /> :' .=: _- • -- -..t.:-.:::- ---_ D.. :TypeofApplication - -• - - -= . . - <br /> 0Site Evaluation 0 Renewal Permit - <br /> Construction Permit ❑Anthoriaation Notice for. • <br /> 0.11 Permit ermit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 MIinor 0 Existm:System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0. Minor 0 Other 0 -Connectit-to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> frhe required fee and attachments are not included with this application,It will be returned to you as incomplete. <br /> Post the orange card atthe entrance to the property. Plea the test holes. - <br /> By my mam e I certify that the information I have furnished is correct;and hereby grant Marion County,authorized agent of the <br /> Department ofRaviromaetr-.tl Quality permission to enter onto the above described property i'or the sole purpose of this application_ <br /> Re-tr ,'- i i o� TR 5 - $173-7157 37 003 <br /> Applicant's Name-Please Print Le ibly Applicaul's Phone Number. DEQ Lic.0 (if applicable) - <br /> 877Ccrsc�c�� /�wu �� E S;lve- -, , a.R 97.3 01 <br /> Applicant's Mailing Address <br /> 1%-_, 1(_______Ile.... --C W <br /> 1501-w Ie <br /> , 7 7 b b 3 <br /> Signature 1 Date. CCB r (if applicable) - <br /> Applicant is the 0 Owner ;l Authorized Representative `ti Authorization to Apply form Attached <br />