10512284 - Laserfiche WebLink

Home Browse Search

k..4, Application for OnsiteDate Stamp: ,.aw,,� pp For City Use Only: City of Wastewater Treatment System MINI"u x� Date Received f �1 / MARION COUNTYPUBLIC WORKS Received by____ ' rJ lC- '-- -.---- -- �/ i'y J a t 1 T .�r) BUILDING INSPECTION DIVISION Zoning by t, t t JUN 21 t 019 5155 Silverton Rd NE Fee Salem OR 97305 # l ;rF�4L—, ;i�1 UNTY (503)588-5147 Fax(503)588-7948 I Receipt Activity# BOLDING 6 .DII a 1N"-PECTION www.co.marion.or.u_5/PW/BuildijInspectio u .! ;..,A: Property(*tier Information; . (..)A 500 '\!PiSvvE 0- t Z l 5 a LaetzT IN.SE &4LCA0(2,S73oZ 503-9 So-SS3a Name Mailing Address City, State,and Zip (Area Code) Phone . B.Legal Property Description . • 093*°LLD 0001 I- St ,ac. Legal Description Tax Lot Acreage or Lot Size Subdivision Name Lot Block q LD LI tANy,5.1:2n CRrsi LN. S. - SBLc\ _ 0Q Cr/30(o Property Address c City State Zip Code Directions to Property: LI CZEtZt_ `n 10• J. TO Cd4' 'EL A\ To {,9J N'c ta. C IiJ t . C. Gxisting Facility/Proposed Facility/Water Information Existing Facility: Proposed Facility: Water Supply: ['Single Family Residence >c Single Family Residence ['Public l L(,. ,`Name + Number of Bedrooms Number of Bedrooms X Private W f LL ❑ Other ❑ Other Well, Spring, Shared D.'.Type of-Application, ❑ Site Evaluation ❑ Renewal Permit ❑Authorisation Notice for: lx Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in U (over 5-yrs old) ❑ Other-Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct, and hereby grant Marion County, authorized agent of tl Department of Environmental Quality, permission to enter onto the above described property for the sole purpose of this applicati L gtot3 ¶2. 1-VR Yvsl-i- . So -93(N-S83a Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) 123S4;L ,Z-27 DQ. SCS E Lrv\ 1 O2 Q11Z02 Applicant's Mailing Address (0-7.0 0.-7....14),12.4_10. ..._ - ( 9 ign. ure Date: CCB# (if applicable) Applicant is the 'C Owner 0 Authorized Representative ❑ Authorization to Apply form Attavi•�c,?