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• • ,0440,-;,., „,z, Application for Onsite For City Use Only: n%c9C .-�� Wastewater Treatment System City ofDate Received,M MARION COUNTY PUBLIC WORKS - Received by 2BUILDING INSPECTION DIVISION Zoning byMARl O lC® 7 5155 Silverton Rd NE Fee BUILDING 1 '-'O T®IV Salem OR 97305 (�, (503)588-5147 Fax(503)588-7948 Receipt# .- C�q' 2, r www.co.marion.or.us/PWBuildingInspection Activity# �' .. - i :... ...........A.Property Owner Information .__.,2-- _._.__ 1'Oh9r+ 7 - O. 60x 51(,,o ; /i A 7 -86y-Ezt7o Name Mailing Address :... , State,and ip (Area Code)Phone# ___. :_. .___B_LegalPropertyDescripton--_ .._—__._.-._....._. -. ®43EoQD DI I oo 0-,4'3- -�5 - - Legal Description Tax Lot Acreage or Lot Size Subdivision Name Lot Block low k)04In-SIStis O� q7,15 Property Address City J State Zip Code Directions to Property: _ C.Existing Facility/Proposed Facility/Water Information - . Existing Facility: Proposed Facility: Water Supply: ['Single Family Residence X Single Family Residence ❑Public 2_ Name Number of Bedrooms Number of Bedrooms [ 'Private Shiro- d well 0 Other 0 Other Well, Spring, Shared '. .._.......... :...............__......-....,.. D.Type o .._..... . hc .yon : ......... Df A pplicati . ❑ Site Evaluation ❑ Renewal Permit /'I thorization Notice for: El Construction Permit ❑ Permit Reinstatement . A Replacing a Dwelling 51 Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major Vq Minor . ❑ Existing System Evaluation ❑ Personal Hardship ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over 5-yrs old) ❑ Other-Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. 5 c L o'e_,,1- l-Ec, ,, .,,s L .C, , c0, 3 -- <C7 i - 3000 R, t `I S `1 Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) 2'ioo &-uc;Lkk- Road W E , .�t, (Do-, 973c . Applicant's Mailing Address . - "/ pc c j6, i o e) 2 (S-311 Signature Date: ` CCB# (if applicable) • • Applicant is the❑ Owner ,—j uthorized Representative ❑Authorization to Apply form Attached G:\FORMS\SEPTIC\S-01 ONSITh APPL SEPT 2018.DOCX Rev 1/15,3/18.