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Application for Onsite For City Use Only: Date Stamp:
<br /> ----------- -----t-1---.= Wastewater Treatment System city of RECE _VE
<br /> Date Received
<br /> Received by _
<br /> )
<br /> 11111 MARION COUNTY PUBLIC WORKS NOV 2 0 26711BUILDING INSPECTION DIVISION Zoning by
<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 Fee MARION �;()uN
<br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION
<br /> www.co.marion.or.us/PWBuildingInsaection Activity#
<br /> SO=amuIv M _ DO•"• itzSMISAINi • $,7 r _p0" 5:0 1 -0 7 _ = r
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<br /> 06/) PheA-etJ 6 53 5(2F-TAI c f. I :5!= ;A-r... -1✓1/7, OA. q 73Z X72 r 09 '7
<br /> Name Mailing Address City,State,and
<br /> Zip! (Area Code)
<br /> Ph
<br /> o::_,.:ne�..#
<br /> PAS_ -An�N =� _» IIa_ � _ NW � =" � NNZM�_ImsG
<br /> (' ',/.0:79.5 ::-•-3
<br /> 9 - 1/63 0 , 37A
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> `/01/2. al4£A L/A! I.'rON5 • 0062-- et78c
<br /> Property Address City State Zip Code
<br /> Directions to Property: /(0112- D©6a DO LA) t ©i F 1U•F1 P j7
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<br /> Existing Facility: Proposed Facility: ater Supply:
<br /> ®Single Family Residence [S Single Family Residence DPublic
<br /> Z a Name
<br /> Number of Bedrooms Number of Bedrooms A.Private W
<br /> af—
<br /> ❑ Other
<br /> 0 Other
<br /> therWell,
<br /> ell,Spring,r
<br /> ing,Shared
<br /> MiariMaI _ ' rI _garSngi7+ie -�Y —C- j - El_alrtl',li -
<br /> r#W14
<br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:
<br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> 13 Repair Permit ❑ Permit Transfer ❑ 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 /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing 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 /> DO,NAtp 1. b5M! S) .5-5F 0 557 •
<br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> C5--, cC6u(c /ft PR SE 5A-a--01 02 9730 6
<br /> Applicant's Mailing Address
<br /> /0,M46'104— (2672,S
<br /> e Date: CCB# (if applicable)
<br /> Applicant is then Owner 0 Authorized Representative 0 Authorization to Apply form Attached
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