Laserfiche WebLink
,+ 7 Z O 6 Y 5- ,wit T <br /> A lication for Onsite <br /> pp For City Use Only: Date Stamp: <br /> =-y;� Wastewater Treatment System City of <br /> Date Received D ���� � n <br /> MARION COUNTY PUBLIC WORKS Received by �� ]\/ L <br /> BUILDING INSPECTION DIVISION ZoningbyrilB 1 <br /> 5155 Silverton Fee _ AUG 0 2 2022 M-J <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Recevity#ipt# MARION COUNTY <br /> www.co.marion.or.us/PWBuildingInspection BUILDING INSPECTIOt'} <br /> A.Property Owner Information <br /> /liaridtre.k K:nInia n 7 f0 so ek.fte ee gd/VE 54.• haul O - q 71 s 7 3V 3—6'S'S 7y g <br /> Name Mailing Address J City,State,and Zip (Area Code)Phone# <br /> B.Legal- Property Description <br /> jr;� 0• .k.G tw L O'-12 W o 2U 00 l 2 v o 1 -3 AC res <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 74042 Ghcty ,j) ec 24 1J G Si- Paul d� 9?/3 7 <br /> Property Address �1 City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ©Single Family Residence ❑ Single Family Residence ['Public <br /> 1 a.. Name <br /> Number of Bedrooms Number of Bedrooms ] Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application _ <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> is Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major `: Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 /> Flow One. eO.%b+ruction <br /> NWati K~zi' So3_ 57/- 1/307 391/711 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> //305 S-1 Q4-e Sf '3AIR14-1 Oie. 4'73/ 7 <br /> Applicant's iling Address <br /> TKl Zgd`` 2022_ 23 7 £t92 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative Gt Authorization to Apply form Attached <br />