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<br /> •,,;, ;k Application for Onsite For City Use Onl - (I\ /7 mp:
<br /> ------ -- -7-J--- Wastewater Wastewater Treatment System City of E.-
<br /> Date Received 1 J
<br /> MARION COUNTY PUBLIC WORKS Received by APR 12 21.i
<br /> (9' BUILDING INSPECTION DIVISION Zoning by Mike-,:Y `V �� �
<br /> 5155 Silverton Rd NE Fee B uu r..i v. INSPECTION Salem OR 97305 .
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PWBuildingInspection Activity#
<br /> ,,.g:.- _..,,o.::.:,_:.::.:.::!...:>_:.:...,.,,,. Pro a :Owner orm on-- -g: _ - - - -
<br /> ihMae/',� /, 7d/ 3'-1 oho Feb/food/lye /->,z,tee ae 973ylo 93a-7570
<br /> Name L Mailing Address City,State,and Zip (Area Code Phone#
<br /> . .. ,.. . . ,,...........:..:::.. :.:. . -... :B:!Le a Pro a _Descrf rion ;
<br /> N) Legal Description Tax Lot Acreage or Lot Size
<br /> N. Subdivision Name Lot Block
<br /> 4 ,3y()c) gal/ROOK,/Alee I Q s �% q73 y
<br /> Property Address �/ City /y� State Zip Code
<br /> Directions to Property: C—, 7-7-Z I, //L1 iV at / /a/211.4, o%LP�. ,_
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<br /> :_..,::-...�`.;::,,.,,,�. � C.Exts F. c :Pro osedF'aclh /:Waterinformatton::::�:_`._-:<;`,t�_�_...:':ti _ �. ,t.s_;;::..._._...,.�::,:��.
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<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> 0 Single Family Residence Single Family Residence ['Public
<br /> /Vf1 1,,,/oi u 3 Name
<br /> Number of Bedrooms Number of Bedrooms %Private _
<br /> ❑ Other 0 Other We ,Spring,Shared
<br /> ._....... .. ....1...-...i..t.t:.,{.1., ..ar:...-.._,..'.:•..:,....:_,_., - - _. - 'i..: - i.h.,4. _ [.n. 5v,it,—.,
<br /> {.,:.:_;.,;,�,.,,,,v,.._..._�,,-::-._ ._c-::_.,t�. . ..:,-.. ., .:`.1_.... e:o hcatlon._..L,......_.... _ ..,.i,:_-i:...,.. . _�;:'?_:,'__... __
<br /> ❑ Site Evaluation ❑ Renewal Permit ■A thorization Notice for:
<br /> ❑ Construction Permit ❑ Permit Reinstatement N Replacing a Dwelling
<br /> ❑ Repair Permit 0 Permit Transfer 11_The Addition of One or More Bedrooms
<br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing
<br /> O 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 /> Z,Nc/ X (IhaiLran 503.991 /69r
<br /> Applican's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> 3�/a as fa'-a4Gad ty/z � 973V 4
<br /> Applicant's Mailingress
<br />, .;4'r� /7,,��� .r x/77/tea/ / ffV
<br /> X
<br /> re/ Date: CCB# (if applicable)
<br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached
<br /> G:\BUILDING INS ECTIONIFORMS\SEPTICIS-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18
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