Laserfiche WebLink
n D <br /> \r\-f-k: <br /> ,, Application for OnsiteCity y: <br /> -;�� ��,,,� For Use Only: <br /> Wastewater Treatment System city of <br /> � <br /> � Date Received �VU <br /> MARION COUNTY PUBLIC WORKS Received by I v LE <br /> BUILDING INSPECTION DIVISION Zoning <br /> 5155 Silverton Rd NE Fee by �, 9 4 �o�� " <br /> Salem OR 97305 Receipt# fkf`'4 r1°N �0�� <br /> (503)588-5147 Fax(503)588-7948 -�� �a' UN <br /> / wwvv.co.marion.or.us/PW/BuildingInspection Activity# \Js� (���r. <br /> i- iiiki r?Q? t E- .-.,.. }.) ... ,.A -,3 A FropertyOwnerInfonnation v ,x ,,. ._ .T.,v_ , _. <br /> ek,v_ c<C� Q._, 1,S�t- *cl a 6. Avrew L Sci •' '\--)30 <br /> Name ' Mailing Address City,State,an•; ip (Area Coc <br /> i i , , _ , , ii a,B Legal Pro a Descry tioa .. .- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> ?6 BO rt S k. (\ s,k- De_ T734i <br /> Property Address City State Zip Co <br /> Directions to Property: <br /> C Extshng tAci jty" 'mposedu l acihty/£Water InTonmation <br /> Existing Facility: Proposed racility: Water Supply: <br /> Single Family Residence AKI_Sint e Family Residence ublic Cam° f fy„;F <br /> e <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other rA Other Well,Spring,S <br /> D T eofA ligation .+ ?-' <br /> ElSite Evaluation ElRen, al Permit (Authorization Notice for: <br /> Construction Permit ❑ P n't Reinstatement Replacing a Dwelling <br /> , Repair Permit ❑ ermit Transfer R. <br /> The Addition of One or More Bedr <br /> (t Major ❑ Minor ®,'Existing System Evaluation" El Personal Hardship <br /> El Alteration Permit r Record Review El Temporary Housing <br /> ❑ Major El Minor, ■ Other El Connecting to an Existing System <br /> (over 5-yrs old) <br /> ❑ Other-Please Specify' <br /> If the required fee and at achments are not included with this application, it will be returned to you as incomplete. <br /> Post the orange card at " e entrance to the property. Flag the test holes. <br /> By my signature,I c: Ty that the information I have furnished is correct,and hereby grant Marion County,authorized <br /> Department of En 'onmental Quality,permission to enter onto the above described property for the sole purpose of th <br /> ;`":',? to 3 J-leit ,S®3-9N 9- 2 77 T._ Z:76cl <br /> Applicant's ►.'ame-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 14/ e u 1+--- -. (t/ j U 1 v O& C 323 <br /> Appli n 's Mailing Address <br /> !__ iG q /4ZA fcc7 Si <br /> :;,j , �i :Jr' � Date: CCB# (if applicable) <br />