Laserfiche WebLink
Iz AW- Z-- <br /> , <br /> Application for Onsite For City Use Only: Date Stamp: <br /> % „, Wastewater Treatment System City of <br /> um <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww.co.marion.or.us/PWBuildin�Inspection Activity# <br /> w <br /> A Property Owner Information i <br /> f)ee'c1 e-c\a.r115 12333 51 dve1 \5-hwv_5Z, Au MSv`,ile, C 5D3.6g 7-lok,52 <br /> y,Name Mailing Address Ci Stafe and Zip cr 2 3�5 (Area Code)Phone# <br /> r._._::_.. . . B.Legal to&LyDescnption <br /> -10 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 948 b A AAe.3cyr►Kck 7ku fv) v i 1 Ie.. OR 9 732 5 <br /> Property Address 1 City i` State Zip Code <br /> Directions to Property: 1 V C9i4\\ (p CS&JP sr V -A\\, 11 <br /> . _ C Existing Facthty/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> '']Single Family Residence -1 Single Family Residence ['Public <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑ Other 0 Other Well, pring, Shared <br /> : D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit i Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 4Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer The Addition of One or More Bedrooms <br /> ❑ AMajor ZI Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> l <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 /> and herebygrant Marion County, authorized agent of the <br /> By my signature,I certify that the information I have furnished is correct, ty, g <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> A e ec 503 .93`7`1o/052- <br /> Applicants Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 11333 5 ,eir \-- \19 5 - ,U �v`► I I e f OK Q1 3 2-5 <br /> licant's i g Adiess J <br /> ISigna in ' Date: CCB# (if applicable) <br /> Applicant is the Owner CI Authorized Representative CI Authorization to Apply form Attached <br /> F:\FORMS\SEPTI \S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />