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ApplicationFor City for Onsite Use Only:y: Date Stamp:
<br /> Wastewater Treatment System City of
<br /> C'�,C O LI h
<br /> MIs -�
<br /> D
<br /> - MARION COUNTY PUBLIC WORKS Date ReceivedReceived by .
<br /> BUILDING INSPECTION DMSION Zoning by V0V 13 2020
<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 Fee MARION COUNTY
<br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILD DNG INSPECTION
<br /> www.co.marion.or.us/PW/BuildingInspection Activity#
<br /> . A Property Owner information ^T
<br /> CHRISTIAN GARCIA 4852 WHITWATER ST NE SALEM OR 97317 503-951-0040
<br /> Name Mailing Address City, State,and Zip (Area Code)Phone#
<br /> B Le al—PARCEL Proe Description
<br /> 2"PROPOSED""SEPT fC"SYSTEM'._�.__.,_____�zwzoiipsat
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> PARCEL 2
<br /> Subdivision Name Lot Block
<br /> 997 IVA LANE N.E. SALEM OR 97317
<br /> Property Address City State Zip Code
<br /> Directions to Property:
<br /> C Existingaczlxty I;Proposeduaclity!Waier Information
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<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ❑Single Family Residence ® Single n Residence ❑Public
<br /> Name
<br /> Number of Bedrooms Number of Bedrooms ® Private WELL
<br /> ❑ Other ❑ Other Well,Spring,Shared
<br /> D Type of Application....
<br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for:
<br /> ® Construction Permit El Permit Reinstatement El Replacing a Dwelling
<br /> El Repair Permit El Permit Transfer El The Addition of One or More Bedrooms
<br /> ❑ Major El Minor El Existing System Evaluation ❑ Personal Hardship
<br /> El Alteration Permit ❑ Record Review El Temporary Housing
<br /> ❑ Major El Minor ❑ Other El Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> El 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 /> TORRY COLLINS 503-689-3872 37956
<br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> PO BOX 962 MOLALLA OR 97038
<br /> Applicant's Mailing Address
<br /> —7 4 ,t CBS 11/4/2020
<br /> Signs a Date: CCB# (if applicable)
<br /> Applicant is the❑Owner ®Authorized Representative ❑Authorization to Apply form Attached
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