Laserfiche WebLink
Application for Onsite• umeSte: <br /> --- ,�_ Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> • <br /> 5155 Merton Rd NE <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> wrirw.co.marion.or us/PW/Buildinginsaection <br /> A.Property Owner Informati n <br /> Name Mailing Address <br /> Uti..S$0\AL.E Ofk 0 a'1 o Sa3-1"LeI-3(aA°1 <br /> City,State,and Zip t (Area Code)Phone# <br /> B..Legal,Property Descript►on... :;- • - <br /> '7Q' 5 W�LOC3En1� L.A.) SE SAtEM OR 91301 <br /> Property Address City State Zip Code <br /> 23a a ( P C st, o8ltAnSoV0023 oa 1-9 Aug <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: IS S ova -C6 OCIAb J5-\/ DC"L4i 11C 'V Ta Wlt'DeG(VL) <br /> C.Existing Facility/Proposed Facility./Water Information. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 3 Number uumber of Employees/ of Employees/ Prime �S� • <br /> g g <br /> We Spring,Shared <br /> D• <br /> Type'of PP <br /> A hcatton .. ,. . <br /> ►:/ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Nkkli C At960-ir c Sa311-ct 3 Coen N` <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> ►ne),0 cW k.kOMS$1.G44X--(l_M.1 Lit k-S-0NVME—L0' g1Q)0 AessitvIcss.mtav-g ,MAIL.C,QIM, <br /> App' is Address Email: <br /> (AriI-14 <br /> Signature Date: 1 CCB# (if applicable) <br /> C:\USERS\ANAJERASAPI DATA\LOCAL\MICROSOFIIWINDOWS\INETCACHEICONTENT.OUTLOOK\FKJL2DXINS-01 ONSITE APPL JULY <br /> 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />