Laserfiche WebLink
DEN deep. <br /> '' .‘., Application for Onsite For City the Oaif: <br /> Wastewater Treatment System Ciry of <br /> Dale Received <br /> `"`- 11.1 <br /> "---' MARION'COUNTY PUIILiC WORKS Received by_ <br /> IIUILDING INSPECTION DIVISION Znning by <br /> 5155 Sllverton 11t1`NE Pee <br /> Salem OR 97305 Receipt N <br /> 003)500-5147 Pox(503)5R8-7948 Activity H <br /> iY ca a aid �41[t >'rtIilly 11110.113ACsIlya - �+` <br /> A.Prohotly oWnor Inlortinatl0n _ _. _ _. '_. _._-._-- 1 a(;� "i- <br /> Nam` l.=l t�\`(�CAE `S�1�GA�e `.?�I 01 1M C U(161 GQ,COC c 1PA.Code)Pborsa#. <br /> Wing Address City,glate,ttrtdZip• -. _ ---- <br /> _ _ Joao Pioparly i]oacripdon _ �,_. ___ <br /> �. lam) St-My Fv � ?— or 2.0 <br /> gal Description Tax Lot Acreage t Size <br /> S\tbdtvxston Name Lot Block <br /> \ c zc RAP-I�nLL. f Yin c trVe U q t5t ,.2-- _ -� <br /> Property Address CityZi ode <br /> _ <br /> Directions to Property. <br /> ` � . . :Pt-Pa <br /> C- ting„Facility�P Fsc <br /> ro_poscd it)!/Ware rInfaana on,.. .......______ _ _ <br /> _ _ _ <br /> Ex sting Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Lid'Stngte Family Residence [Public <br /> t /,� Name <br /> Numbs ,.� <br /> of Bedrooms Number of Bedrooms J rnvete lde (I <br /> ❑ Other 0 other Well,Spring,Shared <br /> _ _ _ _ _ _ .D of A�plicahoit :___'� ;�-` ..___-.___-__._ <br /> ❑ iteEvaluation- �L-Renewal Permit - 0Authorizzation Notice for: <br /> IUV Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> O Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> O Major [J Minor ' 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> • <br /> if the reguiredfee and attachments are trot included with this application,it will be retuned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. <br /> 'By my signalize,I certify that the information I have furnished is correct end hereby grant Marton County,authorized agent of the <br /> Department of Environmentalbaility,pumiiikii to enter onto the above described property for the sole purpose of this application. <br /> PdiA 1) Torn.-- 5M -9 Si-919 3 9029 R .t 96101 <br /> Applicant's Name-Please Print Legibly Applieaat'a Phone Number I)EQ Lic.# (if applicable) <br /> 16 9 SF, ►rriey ..Rd, /cd6 s-L ad 97071 <br /> Applicant's • <br /> I/21123 2 (--8?3 <br /> $Marine ,Date: • CCB# (if applicable) <br /> Applicant is the❑Owner L�authorized Representative ❑Authorization to Apply form Attached <br /> OAFORMS'SEPIIGV-OI OMITS AWL SEE?2013.DOC X Rev MS,3/18 <br />