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c p_ED <br /> Application for Onsite For City Ilse Only: 33512nrip: lln. <br /> •--.., M4 Wastewater Treatment System City of <br /> Z 7:,' ca 0 <br /> NINO nutioN COUNTY PUBLIC WORKS Date Received. <br /> Received by : '-) '‹ <br /> —Z <br /> Z en I . fil. <br /> BUILDING HiSPECHON DIVISION Zoning by.. (f)••• --•-. r—I <br /> 5155 Silve rho'12d Fee NE <br /> M C <br /> Salem OR 97305 0 Z <br /> (503)588-5147 Fax(503)588-7948 Receipt 4 <br /> Activity it 0-S <br /> www.co.marion.or_us/PW/Buildinginspection 4 <br /> A.Property Owner Information ..._ _ ___ <br /> Cj • f‘12_, 33-5"--j- , ,I I re i- I <br /> ri.A1 ce_ CT ir OR_ 573(a. Sii...?cet3yeil <br /> Name Mailing Address City,State,and Zip_ _ _ (Area Code)Phone!; <br /> _ B.Legal PrOpeTtyl?esp_rip_tipn _,_ __ .., __ ___ _ - __ _ __ __ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> - <br /> Subdivision Name Lot Block <br /> 3 3-5. ''SliN/ C,t C - ,..5e..:tri_it OA. C, <br /> Property Address City State <br /> Directions to Property: 2pCode <br /> VZ <br /> C.Existing Facility I Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [?Single'Family Residence CI Single Family Residence OPublic <br /> 51 <br /> Name <br /> Number of Bedrooms Number of Bedroonts 0 Private <br /> 0 Other _ . 0 Other Well,Spring,Shared <br /> . . D.Type of Application <br /> 0 Site Evaluation 0 Renewal Permit []Authorization Notice for: <br /> K..Construetion Permit El Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> 1:3 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> El Alteration Permit 0 Record Review D Temporary Housing <br /> 0 Major EJ Minor 0 Other __ ______ _ El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other -Please Specify <br /> tithe requiredfee 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 boles. _ <br /> By ray 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 /> te f _ 64---IN. to-k -5-6.--7S ._, 5- 1 -._ZY135 _ _____ • <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.# Cif applicable) <br /> -P 0 , 64)x- /03--z____ <br /> Applic 'S M Addres_ <br /> ado <br /> r..-C--- /1-17- 2-1 . <br /> feg703- <br /> Si titre - - bate: CCB# (if applicable) <br /> Applicant is the 0 Owner 2rAuthorized Representative 0 Authorization to Apply form Attached <br /> 0:1FORMS\SEPTIOS-01 ONSItE ArY1,SEPT 2018.DOCX Rev 1/15,3/12 <br />