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a3-bD3l q°t <br /> Application for Onsite For City Use Only: rr Scanty: f( <br /> no- y City of D l .`='{- '\! <br /> «�: Wastewater Treatment System �1 <br /> Date Received D <br /> MARION COUNTY PUBLIC WORKS Received by L <br /> BUILDING INSPECTION DIVISION Zoning by APR 18 2023 <br /> 5155 Silverton Rd NE Fee NMAH I ON COUNTY <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> 503) <br /> www.co.marion.or.us/PWBuildineInsnection Activity# <br /> A.Property Owner Information <br /> JaInQS eaethik 'oup30 eictitutal Rd se J 'on1 7 ?73' a 50 327-?h7%' <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> T/ n 3cv SEG 2 L1P 2 s oo 1.9 to <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 5 oj+hvl- I) (/1/4/OOdS 141) <br /> Subdivision Name Lot Block <br /> 1243o £rdgew©ad t .d sE 5 t q 1352 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Al Private wt.: <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> igi R air Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> [ Major FrMinor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> �p <br /> T"rt!,PtaC,tn bo1 g S dive c S Itto.21 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 /> A&8 54.07C uric-- til q2I{—air/ 3 S t 39- <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO $ 44 Aih ny� t -ai32 C <br /> pplicant ail',: • ., <br /> /a1. 4I , 4 ' `,Z( !595 g 1 <br /> Si:,. iv / I' ' - <br /> Date: CCB# (if applicable) <br /> Applicant is the❑Owner authorized Representative 0 Authorization to Apply form Attached <br /> F:tFORMS\SEPTIC1S-0i ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />