|
J1-m8.1-ta\
<br /> .,,,,, ;;; ,,,, Application for Onsite For City Use Only: Date Stamp:
<br /> =1�� Wastewater Treatment System City of
<br /> 111111
<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 /> www.co.marion.or.us/PW/BuildingInspection Activity# -
<br /> ._,w._ y IL _,_ _.... ,.. . , x , ,, .a A Property *1119113orma ii. L:= „ ,..1 , ... ..:7„ „ ,._
<br /> P 4i//Ot`� 73 y/31A/E $ iec..7t ^`l "3ml .03-35/
<br /> Name Mailing Address City, State,ands (Area Code)Phone#
<br /> , : ._ ' B Legal_Property.Description:_ x_m_ _w r,., _., __;,,
<br /> l s B:/.....I-%3FRivi- U4cSf-� 59ggol 134x Qo
<br /> Legal esc ption Tax Lot Acreage of 'ii'
<br /> Ma: 4 . Ga-is ��/�74oP7
<br /> Subdiv Sion Name Lot Block
<br /> I20 /fr,5 47da/i? h 6. '-kS or g 3g
<br /> Property Address City State Zip Code
<br /> Directions to Property:- , G,, ,mot^ /Ve,' 5,r/ t 7 L ,' �� BL,�iv c , /c c
<br /> )/ rzo,cA
<br /> C Existing Faeality 1 Pro osed Fae li /Water Informahou,-
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ❑Single Family Residence ❑ Single Family Residence C[ Public G*, e774 G'�
<br /> L/ II Name
<br /> Number of Bedrooms Number of Bedrooms ❑ Private
<br /> ❑ Other ❑ Other Well, Spring,Shared
<br /> [. I 77:77 ... _,,,: _- 2=,M. . P.;TYPe Of Application :„-, '.,., :.. ,._.`..._L: :. .v_ ,_ �t
<br /> f%"'/Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:
<br /> f,.
<br /> „kConstruction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> .Rep it Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms
<br /> Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing
<br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> El Other—Please Specify
<br /> If the required fee and attachments are not included with this application, it will he 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 /> �Or? 4s 1 s'�3-29 —Ll9LLc 3 977 l
<br /> App icant's Name—Please print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> pc, gcoc Sl /l7,)/cAy 62 r^, g ���
<br /> Applicant's Mailing Address
<br /> �� _ 2)9/2-a21
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the El Owner ..Authorized Representative El Authorization to Apply form Attached
<br />
|