Laserfiche WebLink
: . 5 S - 00 8 2PMTOk <br /> Ss5 -21-0o$7,82,- P)T H <br /> y k,, Application for Onsite For City Use Only: Date Stamp: <br /> ---�-- Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> Mill <br /> DECE [IW --MN <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE — <br /> Salem OR 97305 Fee AUG 16 2021 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> }vww.co.marieu.onus/PW11?iuildin Inspection Activity# MARION COUNTY <br /> BIIII rnNt3 INSPECTION <br /> A.Property Owner Information <br /> H� 5//t,5 1 ze 1?� sit-A) fir¢ (CJ g73LiZ %' <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B..Iegal'Propq+ Description <br /> i a S E 01 g ecyc 2ac Y c-O <br /> Legal Description Tax Lot Acreage or.Lot Size <br /> l'}awtPA2et Adait"Ye-, /Sd- 16 I Z, <br /> Subdivision Name Lot Block <br /> t (D f3v* g4-- Ai / zi 71- c 12 9-7-s L-(Z <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 ,j Single Family Residence [Public <br /> Name <br /> Number of Bedrooms Number ot Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> El Site Evaluation El Renewal Permit ElAuthorization Notice for: ,y� <br /> ❑ Construction Permit El Permit Reinstatement El Replacing a Dwelling i? rvtn,zk <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> /2 Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 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 /> Cve ms . - t« � s t2e-7�1� /e( .; 6 <br /> Appy is Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PC) goic _//oe TOR 9-7?ki <br /> Applicant's Mailing Address -7—PI-7-( ,,, e1.l6 <br /> Date: CCB# (if applicable) <br /> Applicant is the El Owner 'Authorized Representative ppAuthorization to Apply form Attached <br />