Laserfiche WebLink
ac <br /> - bblt-ka-1 <br /> ,.., <br /> Application for Onsite <br /> NON COUNTY <br /> ....o-- <br /> ,---st— Wastewater TreatmentFor CiiNA---3.---'..'-e Only: 1 <br /> System City of <br /> BUILDING INSPECTION <br /> MINay.. Received <br /> , MARION COUNTY PUBLIC WOR by <br /> BUILDING INSPECTION DIVISION Zoni <br /> n b <br /> 5155&Weston Rd NE g y <br /> Salem OR 97305 Fee . . . <br /> (503)588-5147 Fax(503)588-7948 Receipt it <br /> Www.co.marion,or,ustPW/Bitiltlinelpsitection Activity <br /> ,. . <br /> vl . , <br /> A,Property Owner Information <br /> Name Mailing Address City,State. and Zip (Area Cot <br /> .l B,Legal Property Description <br /> t1 : <br /> .•.,,,, Legal Description <br /> Tax Lot <br /> Acreage or Lot Size <br /> ,..1 <br /> Subdivision Name <br /> Lot Block <br /> .'l <br /> ll Property Address City State Zip Co <br /> 14 Directions to Property: 1 42_ tivklAs-ksze LA CILATIV• ne croi7- . <br /> ri <br /> , t <br /> , A <br /> .- <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Fatnity: Prod Facility: Water Supply: <br /> Ingle Family Residence 'ZilWitrigle Family Residence °Public <br /> ' tf 03 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other 0 Other Well,Spring,S <br /> D.Type of Application <br /> 0 Site Evaluation 0 Renewal Permit I:Authorization Notice for:a Construction Permit 0 Permit Reinstatement E3 Replacing a Dwelling <br /> ; 1 <br /> illg•••Renjr Permit a Permit Transfer a The Addition of One or More Bedr <br /> I.U.,'Major a Minor E] Existing System Evaluation El Personal Hardship <br /> 0 Alteration Permit a Record Review a Temporary Housing <br /> a Major 0 Minor a Other a Connecting to an Existing System I <br /> -, (over 5-yrs old) <br /> Ej 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 <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of th <br /> La0. 2gcl 5954) <br /> ,A.,.. A cant's Name-Please Plint Legibly Applican Phone Number DEQ Lie.# (if applicable) <br /> 1 1 <br /> 0 c). f3oK )qot <br /> t-- Applicant's Mailing Address <br /> ei <br /> 1 , <br /> CCB 4 (if applicable) <br /> ,--,- <br /> Id <br />