Laserfiche WebLink
Application for Onsite For City Use Only: DEea`O I LUC0 <br /> 4' City of �� <br /> — %; Wastewater Treatment System <br /> Date Receivediii• -,,,, <br /> IViA►�ION (;O(JNTY <br /> MARION COUNTY PUBLIC WORKS Received by BUILDING INSPECTION <br /> BUILDING INSPECTION DIVISION Zoning by )-P--OC,75 S-i <br /> 1 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> LJOI-IN R MARKS 2.83 Elb R AvEsE SALLIM oR 9730 503 3103-974o <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> DO GW 001 ALAE S)LoT(cx o9EISAA OD Soo 0x3(0 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 211'H -DOG Wo 0 D Pt cRE s 6 <br /> Subdivision Name Lot Block <br /> 1 028 Do6 tivooD LN sE_ L'yoNs OR <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence (4, Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> O Other ❑ Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ] Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El Major ❑ 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 purpose of this application. <br /> JOHN R IU171RKs sO3 363-974-o <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Z83 E/.7)E/Z AVE SES -SAL E tv1 ) D rk 97306-3414- <br /> Applicant's Mailing Address <br /> Signature Date: • CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />