Laserfiche WebLink
Application for Onsite <br /> For City <br /> Use Only: gjaKStamp:, <br /> ���� Wastewater Treatment System city of ®> . MI <br /> Date Received 5� ri-i <br /> IIIIIII MARION COUNTY PUBLIC WORKS Received by G)0 OD " " <br /> BUILDING INSPECTION DIVISION Zoning by Z p <br /> 00 <br /> 5155 Silverton Rd NE Fee -D® ® <br /> Salem OR 97305 - - MC N <br /> (503)588-5147 Fax(503)588-7948 Receipt# a z ®. <br /> 111-1 <br /> www.co.marion.or.us/PWBuildin2Inspection Activity# =I. <br /> E A hif ii f'I.netlnfort atip n <br /> zc...,..�."��....�i<�..""_ ` ----�--- �-------- --------- E ........ ........' ... .--B......- ........,....... ._ .....-.--. .n.-.B -.»...o. <br /> /oss M,// C 12155 evJSumvnevl J gct/cL 6l2 g7Z23 503 -Wt -102Z1 <br /> Name Mailing Address City,SYAte and Zip (Area Code)Phone# <br /> <: z - ��egaPltctyTtl�vF pVec 2 J , px . 3 .3,. <br /> 100 �syC 3 2. e3Joo m .8s <br /> Legal Description Tax Lot Acreage or Lot Size <br /> g*/A//S €lk11E,c77i 7- 3 <br /> Subdivision Name Lot Block <br /> 35'125 2c ►. Si- 5. .--- Lyo#iS. .--- V r-- T73S� <br /> Property Address Ci State Zip Code <br /> Directions to Property: , /l/'. 7 ' ` �/di- <br /> p �Y= r a � � � _ ,� _.1,4 a yM10- <br /> ,....-.;F..F. MH.,M EENB ,, Z ..... C..EWtl WF49fliyI Pi•opoted Faczlriy1, tO>r tg9.#oatzvp .w.. ta, .,MSN EEMOIMti. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Famil Residence Single Family P1esidence ❑Public <br /> / Name <br /> Number of Bedrooms Number of Bedrooms Pf..Private R4-1,e4, <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> EatEallatltagT of Apphcatton -- --- --- ---. - -------- : bi litfil <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> a Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major n Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other–Please Specify <br /> p/qce 74-n k r t2,ki.b+41+mn So(Y- . . <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 /> Sons 5,9r -GC. ScD3-097-I/yL/.r, 39Z <br /> Ap icant's Name–Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> ipo .8,7x 5l /17//I e /?'y �r7.�. .7 9336 <br /> Applicant's Mailing Address <br /> ;� Gr�— J/ /;247) / <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the[i0 Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />