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5S5TZI- Do6240 PRM - 01 Application for Onsite For City Use Only: Date Stamp: Wastewater Treatment System City of „_.., Date Received_______N.- © MARION COUNTY PUBLIC WORKS OM Received by L' yr_i BUILDING INSPECTION DIVISION Zoning by ,JUN 15 2021 5155 Silverton Rd NE Fee Salem OR 97305 Receipt#_ MARIO COUNTY IVTY (503)588-5147 Fax(503)5$8-7948 Acvity# � BUILDING INSPECTION www.co.marion.or.us/PWB Acti uildineInsnection k Li V:' ,�+ 1.:-. � �i � � Q� ,� , *T..`'t9 y��$na�.arp X.y. ^�°_r zA '•.Fr �� "w ,!� �+ i �-•-' uNta -,ON,:, �s, `E aaak x . .::x+L ..-z."3 `°� .. '0.2,r\tvt lc. `)\S x. 2°I oske sw iovih..4_ 150r.v\t, vQ- °11 q11 -3M- ►l12- Name Mailing Address • City,State,and Zip Area Code Phone# r i'' s .ar, rn -.k ^; a a7 i 4r t z,+ ,Y ,Sr�Tr.ls "sY ' ar t�TFR"'_ „'.± ar ,.,d' ''�" y ..a: g",{is ta, i 74 �. ;M� �'wx�,"�i��,��.tv ' � � �l�,a^�c�,e�� ? r��_��+t;3°" 41,��.-�� ° �°5��. rn��;;..,, i'�n+'� "� cr... '' �7 ;.c.�n.�•r-a?�tl Legal Description ' 'fax Lot . Acreage or Lot Size Subdivision Name Lot Block 200 t - - . roar — q'1 - — Property Address City State • Zip Code Directions to Property: • Existing Facility: JJl Proposed Facility: •Water Supply: Single Family Residence [ Single Family Residence •( Public �' \IU OI'Ve 2.— Nan Number of Bedrooms Number of Bedrooms ❑ Private ❑ Other Well,Spring,Shared 0 Other. 'goal,13 1a ; t ww a , g + . »aT " � � " t': 7 F*.4. >< kINk - -414P. ka❑ Site Evaluation ❑ Renewal Permit• r Authorization Notice for: - El Construction Permit El Permit Reinstatement [Replacing a Dwelling 'Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms [ )Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing El Major ❑ Minor E Other. ❑ Connecting to an Existing System Never in Use (over 5-yrs old) • El 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. • • IPA«- Siz �`ZZ. 5--0')D=3C3-AZ5- 9,1-)\ 1-S Applicant's Name—Please Print Legibly • Applicant's Phone Number DEQ Lic.# (if applicable) �.0 bob °ti fl 190yoili.,b of 9 13�5 Applicant's M ' 'nA dress Lk\ k‘ on a 1.K Signature Date: CCB# (if applicable) Applicant is the❑( er • )Authorized Representative • [)Authorization to Apply form Attached 1 I_