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s-i-Sr 21- O0c Oer O - NLECEV-IE
<br /> P iz M-r- JUN 11 2021
<br /> ,i�,,,, Application for Onsite For city use only: MARION-COUNTY= Wastewater Treatment System city of BUILDING INSPECTION
<br /> 111111
<br /> Date Received
<br /> MARION COUNTY PUBLIC WORKS Received by_-_
<br /> BUILDING INSPECTION DIVISION Zoning by
<br /> 5155 Silverton Rd NE Fee
<br /> Salem OR 97305
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PWBuildingInspection Activity#
<br /> A Property Owner'Informatxan l
<br /> Y A3
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<br /> ??Y`r,kirthern .5,20 el tramp el Si, Qa, 1 ts3z 9'7 n 37 ' Su; - 5/b —/7 a-7
<br /> Name ailingAddress ' City, State and (Area Code)Phone#
<br /> � tY, Zip
<br /> n,, e i s ' B Legal Property Descnptinn 3 3 ... . . _1 13 ,2 . 1
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name ' Lot Block
<br /> 22-Lf)-1 P—‘ Q0.-_.1 51-• Pau 1 o 7 ( 3f7
<br /> Property Address City r State Zip Code
<br /> Directions to Property: kV'W 2
<br /> l _: ............ n Existing Faellity,l Prapofed Facility/W titer Information..',
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ['Single Family Residence NC Single Family Residence ['Public
<br /> 3 Name
<br /> Number of Bedrooms Number of Bedrooms EPrivate
<br /> ❑ Other El Other Wel Spring,Shared
<br /> tion
<br /> .,_wm.33 w u„.. .-.. ,,,,,���,33 �3 ___, .._ .i ..,. ,, D:Type of App
<br /> _ lica
<br /> , F.. 3
<br /> ._,.. . I 3iv3A.>>.: .,e,... <., _m
<br /> . "
<br /> ❑ Site 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 /> ❑ 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 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 /> ` n&t,,-r• k.-W-29.-..n S-D 3 S?6 — / 7 d 7
<br /> Applicant's Name—Please Print Le ly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> Applicant's Mailing Address X_____., Cel.3/
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the❑ Owner •Authorized Representative 0 Authorization to Apply form Attached
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