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ApplicationforOnsite
<br /> pp For City Use Only:
<br /> =�-� Wastewater Treatment System City of Li
<br /> Date Received
<br /> N
<br /> ,r, MARION COUNTY PUBLIC WORKS Received by OCT 0 2 2020 ,
<br /> BUILDING INSPECTION DIVISION Zoning by �/,t�RBO ., CC7
<br /> 5155 Silverton Rd NE Fee
<br /> 131�$1_�I .EC;� ®��
<br /> Salem OR 97305 °VS���1-JOS
<br /> (503)588-5147 Fax(503)588-7948 Receipt# ^CTQS", .i Le 3
<br /> www.co.marion.or.us/PWBuildinglnspection Activity#
<br /> _,..__ 2:1 _.L, 7,____s :"il ._,.___f2..A Pro'ertyOwnerIriformatt►" ,.__e.._ .. .a _1__.1 _- 6_ ..i': "2
<br /> �J _ (3I�,
<br /> Name Mailing Address Ci , tate,and ip (Area Code)Phone#
<br /> a�_._._ ' ''t'�.� u 'y __...;B..Legal Property Descrtphon. ._. ,,.:_ ....v.,.._,. __a_ ,,L;._.'.___ N_._ .... ._._ .. .
<br /> Legal Desc ' tion Tax Lot Acreage or Lot Size
<br /> / $i
<br /> Sub - ision Name Block
<br /> // 7 4u4::j:ij,i kb,if 6ervai� I-7,02,4.
<br /> R'ro�erty Address City State Zip Code
<br /> Directions to Property:
<br /> -51,1'2,,,.--,ii,'2„.. _I _r_.____ : ,1,_:„:2,,,e:2,,,:1,CExisting Facility/Proposed Facility/Water Informahonzv .__._,:.L_ :_ �. __LL_,i..... _,_ _n,r..,
<br /> Existing Facility: Pr posed Facility: Water Supply:
<br /> 0 Single Family Residence Single Family Residence ['Public
<br /> Name
<br /> Number of Bedrooms Mier of Bedrooms 0 Private
<br /> ❑ Other ❑ Other Well,Spring,Shared
<br /> _ .: t .::: 7 ro_.. - '. ,21 k D Type of Application_ .. _ . _.., . .m.,_ .__r ._ .._„.r�.-.. . .., .,.. r,. „_z,,
<br /> Vite Evaluation ❑ Renewal Permit ❑Authorization Notice for:
<br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms
<br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing
<br /> O 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 si 1•.ture,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the
<br /> Dep. .a e r t of Environm ta1 Quality,permission to enter onto the above described property for the sole purpose of this application.
<br /> .i+-,— A - .��D— (,, b�) 9c7 X441
<br /> Applic. ame—Please Print L bly Applicant's one Number DEQ Lic.# (if applicable)
<br /> • •plicas 's Maili/jlVt
<br /> /
<br /> •.... a• e Date: CCB# (if applicable)
<br /> Applicant is the Owner
<br /> 0 Authorized Representative 0 Authorization to Apply form Attached
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