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<br /> �: Application for Onsite For Clty Use on►y: Date St.,r
<br /> _ `��\ City of C
<br /> Wastewater Treatment System r> M
<br /> Date Received 0- -,
<br /> MARION COUNTY PUBLIC WORKS Received by n 0 - v v
<br /> BUILDING INSPECTION DIVISION Zoning by O
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<br /> 5155 Silverton Rd NE CD-0 "t `�
<br /> Salem OR 97305 Fee -0 0 il
<br /> Receipt# C '
<br /> (503)588-5147 Fax(503)588-7948 01
<br /> www.co.marion.or.us/PW/BuildineInsnection Activity# - -1
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<br /> A.Property Owner Information
<br /> Tiffany Gwinn 4045 Illahe Hill Rd S Salem, OR 97302 503-931-5029
<br /> Name Mailing Address City, State,and Zip (Area Code)Phone#
<br /> B.Legal Property Description
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> 754th CT SE (New Parcel) Salem OR 97317
<br /> y Address City State Zip Code
<br /> Directions to Property: Gath rd, to Lipscomb, then left on 54th ct
<br /> C.Existing Facility/Proposed Facility/Water Information
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ❑Single Family Residence 2 Single Family Residence ❑Public
<br /> Three Name
<br /> Number of Bedrooms Number of Bedrooms Private Well
<br /> O Other ❑ Other Well,Spring,Shared
<br /> • .w. D.Type of Application_ '
<br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for:
<br /> NI 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 /> O Alteration Permit ❑ Record Review 0 Temporary Housing
<br /> El Major ❑ Minor 0 Other El Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> ❑ Other-Please Specify
<br /> .. i• diti1
<br /> If the-required fee and a tachnzents are not included with this application, it will be reigi#11 ta you as incomplete
<br /> Post the orange card at the entrance to the property. Flag the test holes. u; , „ ,, ,,,, iiiii : :.,hi ,,,
<br /> By my ignatilre,1 I certify that the information I have furnished is correct,and hereby grant Marion County,`authorized agent ofllhe I' ',,"I"
<br /> Department of Environmental Quality,permission to enter onto the above described property•for the sole purpose of tlis'application- ,
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<br /> "J 503-551-4548 '1 :: ,q ti
<br /> RodneyGwinn , cans^n f Pin ,: .
<br /> Applicant l"s N' 'e-Please Print Legibly Applicant's Phone Number DEQ Llc•# (1f applicable)
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<br /> 4045 IIlahe ills Rd Salem, OR 97302 , .I, . },: ,,; ,I, I ,I ,
<br /> Applicants gailling Address .,71;IIli-tl .:I.. ,lull iiIIW:4a 6u;ft,'.,i: ,a:•'_;,,I1u,.
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<br /> Signature CD W Date: CCB# (if applicable)
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<br /> Lii Applicanti❑s the Owner ❑Authorized Representative ; ❑Authorization to Apply form Attached
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<br /> v) F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX.Rev 1/15,3/18,6/22
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