Laserfiche WebLink
• � o. 0 --FVt - ', r <br /> • <br /> Application for Onsite . For City Use only: ..,li <br /> • Wastewater Treatment System °f ��n • <br /> Date R eccived 11 " I. <br /> MARION COUNTY PUBLIC WORKS • Received by <br /> _BUILDING INSPECTION DIVISION Zoning by Z <br /> . 5155 S>Zverton Rd NE F O z O <br /> Salem OR 97305 0 1\2 ' <br /> (503)588-5147 Fax(503)588-7948 Rczerpt# O <br /> ,� rrw.co.marina.onus/PW/Buildfnglnsoectioa Activity# C et <br /> �. <br /> T/-ffort Ao t O Information <br /> �r►/*s 4 ,S'o vA Prpery Owner O <br /> /zs-y 3�...vd 4kt timi 5.44s4 U4 '73.oy s01-363-70a/ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property De;seription . j3 .9qp. _a3 - <br /> • a, 3g <br /> Legal Description • Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 703 /s'` S7►te-e7 5co1 s m,LLi a/e 1737S <br /> Property Address • City State Zip Code <br /> Directions to ProP F --T.- s �e 3s T <br /> ili} wy Tv C'sr 0=iRe, 5.7-.9-7-1 s•L) <br /> C.Existing Facility/Proposed Facility/.Water Tnfi,rrnation •• <br /> Existing Facility CProp°sed tarty: Water Supply: <br /> Single Family Residence kJ Single Family R mi Arpr7 - • ®Public 5(-47T.S m a L l S <br /> • <br /> 3 (y)Q '941 Name <br /> Number of Bedrooms Number ofBedro�s ❑ PIIvate • <br /> ❑•Other ❑ Other • Well, Spring,Sired. <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit <br /> ® Construction P ermit 0 Permit Reinstatement ent ❑0 Replacing a Dwelling <br /> for: <br /> ❑ Repair Permiting . <br /> 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing Syatedu Evolution 0 Personal Harci hip <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an ' <br /> tug Pads' System Never in Use <br /> (over 5-yrs old). <br /> 0 Other—Please Specify • <br /> If the required fee and attachments are not inclvtlr1 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 finished is correct,and hereby grant Marion County,authorized agent of the <br /> D <br /> ep <br /> artment of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 77F40yn/IS L cvet. • 60 3 -70 -A3 ,S <br /> Applicant's Name—Please Print Legibly •Applicants Phone Number • DEQ Lic.# (if applicable) <br /> /2fsf 3aAid /4e, ti ✓ ��p <br /> y -/�tµ. Un 973oy . <br /> Applicant's Mauling Address <br /> X"j01/-X...--- /0 -a.6- 2.ri2-0 <br /> Date: CCB# if( applicable) <br /> Applicant is the,Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />