Laserfiche WebLink
• <br /> • <br /> • <br /> 41141100:;411, Application for Onsite For City Use Only Date stamp: <br /> . Wastewater Treatment System city of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS • Received by <br /> _BUILDJNG INSPECTION DIVISION Zoning by • <br /> 5155 Silverton Rd NE Fee <br /> ' . Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> villi'.co.marion.or.us(P`>;�Buildinglnspection Activity# <br /> • • A:Property Owner Information ' <br /> Na,4sc, 4 , ;i(ei g633-4),b4,544, , 4_1_,_,__, g_22_53.,,b —�0 3 L13.2 -093 <br /> Name Mailing Address City,State,and Zip '(Area Code)Phone# <br /> ' B.Legal Property Description • . . <br /> Legal Description Tax Lot Acreage or Lot Size ' <br /> Subdivision Name Lot Block ' <br /> % 3 (A)4b4 s.l,,,or,A11 ogitoGPIin q-730 — <br /> Property Address r l `f( C_�• tate Zip�Code <br /> Directions toe roperty: /V 6/, 14 . , /çpc )icj ) t ) (3 VI WGCOv►dU d,e) akt4o <br /> C.Existing Facility/Proposed Facility/.Water Information . <br /> . Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ['Public <br /> • <br /> - <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> p-Other ❑ Other We 'Spring,Shared . <br /> . • D.Type of Application' • <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction}?ermit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit - 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> • ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 ConnectinganExdstin <br /> to g 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 /> Na41'nA.f:// -r S S . .5-P._ -q&2-0935 <br /> Applicant's Name—Please Print Legibly •Applicant's Phone Number • DEQ Lic.# (if applicable) . <br /> 5'.3.5e'-- )J5) • N/0/' /C// 7- , 54ieg4 6,k g23ate-- . <br /> q•plicant's Mailing-2 ddr- • <br /> • JJ • ' •1__ _„ /9.// •ignature Date . . . CCB# (if applicable) • ' <br /> Applicant is the ner lt,Arthorized Representative El Authorization to Apply form Attached <br />