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Application for Onsite . For City Use Only: Lam? �S':eto,� �3:1 • .- , Wastewater Treatment System City of Date Receivediji — MARION COUNTY PUBLIC WORKS - deceived by ��21 BUILDING INSPECTION DIVISION Zoning by V'AR,1ON co" 7 5155 Silverton Rd NE Fee kUILL (f G INS -pEr T ON Salem OR 97305 2-f Us c�5 �(q (503)588-5147 Fax(503)588-7948 Receipt# www.co.marion.or.us/PW/BuildingInspeetion Activity# : . . : -. — . A.Property"Owner Information _ • J 11 EVa'4ic (a j3oI— BOO 61 '—d/J , O - 41331 . .533-'31.-- tX Name - Mailing Address _ City, State,and Zip _ _ _ ._(Area Code)Phone#_ _ B Legal Property Descnphon Legal Description Tax Lot Acreage or Lot Size • / .1A-f4 . Subdivision Name - Block f/ 1 Lot 9 7 • Property Address a City 1, State Zip Code • Directions to Property: Avl}- Ael p4 Scb{ S Gku 1(5- /- y /c; me6,2- _ (i-J'4Yiu 64Ti _ C:ll-,w 04\- W k1/4 1 j a (J L.e 4/- /7 i- 1d'L,r F e L' 13( ( Q e.J tgarN iy,::;: . . . -- - - — — -- - acilrtyl`_WatErInfoiniation' Exisfang:Faoihty�fPL;opos�ed� Existing Facility: Proposed Facility: Water Supply: ❑Single Family Residence X Single Family Residence . ['Public • Name t Number of Bedrooms Number of Bedrooms Private €jc;44--/ • ❑ Other • 0 Other • We Spring,Shatdd — - •— ,.. :. . y PP - -D.T e�of A lication •.- ❑ Site Evaluation ❑ Renewal Permit nthorization Notice for: ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling - El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship Alteration Pe t ❑ Record Review ❑ Temporary Housing - ❑ Major Minor ❑ Other IX Connecting to an Existing System Never in Use Nee/ i' ?�,,,,,,ip _ (over 5-yrs old) - ❑ Other—Please Specify -SEE SAS-/3-0of° -1- ,s p 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. Xi g £- VOAJ AG%-£. So 3—q 31..— 3-&i 8 /VA- Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) `��.o, 30x 800 ,• Si Ic1 did I w- q -3 g1 Ap 'cam's M ' Addre s . if/L,F1 vo-K /- 9.0 - 5.01-1 /1/A- . Si ature Date: CCB# (if applicable) • Applicant is the KOwner ❑Authorized Representative ❑Authorization to Apply form Attached GAFORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18