Laserfiche WebLink
• <br /> 2'f- 0-0/-037 PPi4i <br /> �, Application for Onsite Date Stamp: <br /> --- Wastewater Treatment System E © _ u E <br /> MI MARION COUNTY PUBLIC WORKS <br /> .:9) <br /> BUILDING INSPECTION DMSION MAY 2-9 2024 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information Dl a t1n_ y I t 3icy gleffe wa7 Q"r- <br /> Name Tuv•42v 0 e- q7,3 q Z Mailing Address <br /> 7 56 a 6Z3 0 3 Zo <br /> City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description 3 LS edge dge Doty 006 .S.' T✓✓He V 0 /q 7.3g z <br /> Property Address City State Zip Code <br /> og3 \VolD 0zSon 554#508 S Acker <br /> Parcel II Tax Lot Acreage or Lot Size q <br /> Directions to Property: E/1rI.Ak1 Way CS) vn c/o�'e�rdat/e (E) -f,,ril t 1 5-j Cs <br /> - vvn I'?. aPi r,d rway ,: se () - qo 37 Gm Q,-rtv� of r_p rA,T <br /> y � � y <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> J 3 ......------ ' f- ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees! %Private W f,J t <br /> Seating Seating <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> Construction Permit El <br /> Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major MMinor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> . ❑ Major 0 Minor 0 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 /> Dvane, ?i iga. 36a 623 032_0 <br /> • <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 3 2-5 I' e c 1e lx.cltt of SE_ e tivrer, OP— 9737Z d r,/1,e / i <br /> ,ve,Gl <br /> Applicant's Mailing Addr s Email: <br /> D,„..4,..._ u( 5129/7.4- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ' Owner ❑Authorized Representative(form attached) <br /> G:IBUILDING INSPECTIONIFORMSISEPTICIS-01 ONSITE APPL JULY 2023 REV 6.23.DOCX Rev 1/15,3/18,6/22,6/23 <br />