|
��•'�. Annlication for Onsite 675 ®� �L��y r ��
<br /> PP For City Use Only: Date Stamp:
<br /> • Wastewater Treatment System City of re ECEE1WE
<br /> Date Received
<br /> MARION COUNTY PUBLIC WORKS Received by ■
<br /> BUILDING INSPECTION DIVISION Zoning by - M AR 13 2023
<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 Fee MARION COUNTY
<br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION
<br /> ww.co.marion.or.us/PWB !I uildinnsDection Activity#
<br /> w
<br /> ------,_�.-_;_:_.:-...._.__...r::-._::::_:.:,:;i:.: ....:::..:.._..=--_......._........___:.... ,:.-- - -....._ __...,::_:__.....-.._::cv..._._.: ..-.!!r:.�:.,........ -"--'--......_....._..v..........................1.: ,.r. ..,._.. .__._.._..._.... .__._... ,.ci:...........r.:::,.: cici=v. _.._.... .1....,.-...,.:._...v......... - --- - -----
<br /> :.._......._r.....v,,.,_ ...,..r_.__.._. ..... ._._...�.-rvx:_=:..:a:..::_--:: ..... : .. .._.._.__,_.......,.._,...�:�!-,v,::�!.:.............:.........:._.......:�_.�,:�:::::::k-::l_Ffi;::;!__ _ �._'vei1_=:!-
<br /> F,:—.,.-"_......:r.__..,.._......,_...,,....i,._�a<........r......_._._..__. ....._ ._—.._:.0II.f... _.._., .. _,....
<br /> __..__.v. ........_.....,.v._....r_.....,.._.._u_..:..x_...__I ....,. ..__..._._ .............._. : r .. _... .. .: .:v:_::,::n-:-er..__..____�;:1!::F:!�F::._.:.... _.,!�.._....:31::nitc __ — ___
<br /> Oa.tivv2. k Jr(sc'v\. C)I L Ctl} ba& ,c,vt a RIM -ti-,��aS So 3,12 go -0 21
<br /> Name Mailing Address
<br /> C ,State,and Zip (Area Code Phone#
<br /> !,rt r�l'If;" !.r!:..:.:._.a....:i;!fi;!: ,6 I =;u tif5'�._.;__:,-:_,.:_:::!::-::=;!-�-�,,-'..-::-:_;_: -. .-__- -r,,.:„! :...:.:.. ,.r� ... �gI y9 F6 4 _ _uu.�::::- I'� k -_ ,,I'•
<br /> _ ... ,..._.,..._...:..,_F:!v:�'_:-.:..:.„� � rrv...-..h '1p� �,�.�_'�" _� _._
<br /> L_:..u:_= _.___-_.....�-�.—,___-. ,_,- :.:,:����6���D."1�`�.''.T7xuc���e�T�:
<br /> rr
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> 1$gbt B -WeAt)itte.qA Nuf\A,1 OR G1:-Lu o'2�
<br /> Property Address City State Zip Code
<br /> Directions to Property: VrZo y \.5 20 cst�
<br /> ._.:..........._.._.,...__....._...._... .. ... _. �^...... ... .. :..., .. - .,. ::.,.. _ III. .:-,:__:�::-.-:._...._ ...,I.._:.1.._...I..__'__..__.____........_,.._..._L._._....._._
<br /> .r.�._................L,._,_,........._......._.._...._..__....::::::-:.,.........__.........._.__.'_._..__...........__... .. .. .. .._.}}. �. I ..... .. f:I,c=i;Gie_-���-°�.:.,:_"'._4:�,rF:,u:a�:��......r..__......__..__._..._..._.:.._...._.,.._..__.,..
<br /> «uw,.........- ._......,...._......._......�......................m-..,..,,..................w....... �...,....,..,,...� �...... ...-..v— .....a.za...... .,...�.-...w.«...,.........1....w,....,.,-...,..LN- .aw..�.,.+«na.,:»....
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ❑Single Family Residence 0 Single Family Residence OPublic
<br /> Name
<br /> Number of Bedrooms Number of Bedrooms ❑ Private
<br /> ❑.Other ❑ Other Well,Spring, Shared •
<br /> ,..,_._aa..__r_.......__�......_..I... I ...,......v i..l....: ._. ....I.._.ay.._.. .. ..Ir,._... ...r.. - .v... .._.. - ___ -_ ____ ,:::y3
<br /> ..I.._..__- :..n... .r._.i. ..::r,.....,,.v.r................_....:.....__....... ..v_.., ,........ ,.n_....la_...._._. ._...n�_...v_....n_u._..v............._..._._.___.._._.,....__...._.__-__...r_
<br /> _.._.-._...ly....r�:_.._..:�:.v_:m:-:.:::::::,�.._.: ::.,.I.......::_._ : v_:! _.....,,!r...�..:...::..........!................ � ...._._............_.._....,.......__..._. _- ____- - - _—_-:1'_�:�cc:iE::Siii F!!::h:,_l
<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, itwill 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 /> &Am\e_ If-\)\)),RAZ-‘0\r - 50 3 - 0 OD - D-AO
<br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> A plicant's Mailing Ad ss
<br /> Signs e Date: CCB# (if applicable)
<br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached
<br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22
<br />
|