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dg-Deja LI 626
<br /> Application for ®nsite City Only:
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<br /> ,„,ems For Ci Use Onl D �I
<br /> ' 411
<br /> - - Wastewater Treatment System city of
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<br /> Date Received
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<br /> `~ Received bye® 23 2022
<br /> MARION COUNTY PUBLIC WORKS HA
<br /> BUILDING INSPECTION DIVISION Zoning by MARI DN COUNTY
<br /> 5155 Silverton Rd NE
<br /> Salem OR97305 Fee Bd�i�DIE1Ca INSPECTION
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PW/BuildingInspection Activity#
<br /> i,'. .,_ _, ,._.__ ..._.._ ,. . . .s . ...KA Rtoperty;Ownei Information , t' ... _ ` .... '
<br /> rd-t,,,,,r4 Ovmail G-z' (4-6- C-4-ilr6 rA ie.0-1 o 77/7
<br /> Name Mailing Address City,State,and Zip ()!Lrea Code)Phone#
<br /> :r`..`_'__.,., v_r . <.. .: ..... ... .. B Legal PropertyDescripton __._ : 3:Y. .2 .-.,. .__- MOVI_.. ` S
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> (2 L\ C OvlAgir CA )j' ) S _ On lot a,
<br /> Property Address City State Zip Code
<br /> Directions to Property:
<br /> is ti r.. t_`_,.giUM.. _... C E Oi g, 'ae ity(Proposed Factltty/Water Tiiformatton .. ._.j, __-. _ °.a, . .
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> (.Single Family Residence ❑ Single Family Residence [Public
<br /> 3 Name
<br /> Number of Bedrooms Number of Bedrooms [A Private ‘„/ I J
<br /> ❑ Other ❑ Other Well,Sp
<br /> D Type of Appl�catioii , x . .
<br /> ,
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<br /> 1 ; �
<br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:
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<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 /> N,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 /> 13 A&1 CcLlir4 Ai 5 �'o3-7ci 3-23LI3 3 619 8
<br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
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<br /> A 'cant's Mailing Address
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<br /> ' 1 \1 aa- yys_
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the❑Owner Authorized Representative ❑Authorization to Apply form Attached
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