11989610 - Laserfiche WebLink

Home Browse Search

O/f1 f/41i O ( _ r— Application for Onsite For City Use Only: Date Stamp: '; �}h --=— = Wastewater Treatment System city of :)% z. ,n Date Received . = _ MARION COUNTY PUBLIC WORKS Received bye'a``'. C. 't\113 BUILDING INSPECTION DIVISION Zoning by 2- C "'I - ' 5155 Riverton Rd NE 'l N '------ FeeE r U u" Salem OR 97305 ��C. r� (503)588-5147 Fax(503)588-7948 Receipt# ' . 0"'` www.co.marion.or.us/PW/Buildint=_Insnection Activity# "'. r--- _.... °.. ... Property tOwner Information Se.r 1 Ala 6Z 13039 ge-fhl-them Dr Gcrvo O2 97026 Name Mai ling Address City,State,and Zip (Area Code)Phone#........................... , , B Legal Property Description . .. __ ._.. .. ., , ..- .........- ,O 1, 1�.e•I1 it h e ri Dr N F e 5 Legal Description Tax Lot Acreage or Lot Size Subdivision Name Lot Block 13039 -I?C441 1-e 11 -► i .fir Gervo ;S 0 R G7oz6 Property Address City State Zip Code Directions to Property: NiiiiiiiiiillailiarC Exstln_gµt.S lIProposedFaclltty{Waterlllformation, .._........_ ;: Existing Facility: Proposed Facility: Water Supply: OSingle Family Residence (Single Family Residence ['Public Z Name Number of Bedrooms Number of Bedrooms ❑ Private 0 e.l ❑ Other ❑ Other _ Well,Spring,Shared i D Type a A S.44tiaila El Site Evaluation ❑ Renewal Permit _'i('.cliorization Notice for: El Construction Permit El Permit Reinstatement [ ;placing a Dwelling . El Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms Major El Minor El Existing System Evaluation ❑ Personal Hardship re-Xlteration Permit / El Record Review ❑ Temporary Housing El Major ©Minor El Other ❑ Connecting to an Existing System Never in Use (over 5--Prse old) itt4T1,4pri-/ ❑ Other-Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. • Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. ,S ,C9 y Alarc)-2_ .ii-71)-?..90--72_99 Applicant's Name-PleaseTrint Legibly A' plicant's Phone Number DEQ Lic.# (if applicable) 13 03 9 13-e.11I e rle•1Y1 Di& NE Ue`Vc 5 or 9 7 62- Applicant's Mailing Address .1 I ! 071'2-Z- • . Signatur Date: - CCB# (if applicable) Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22