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c;93 -64046��1 v16 <br /> Application for Onsite For City Use Only: 9 E C EiYam g <br /> ._.., <br /> - Wastewater Treatment System City of <br /> iiii• Date Received - J U N 012023 <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by MARION COUNTY <br /> 5155 Silverton Rd NE Fee BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# <br /> www.co.marion.or.us/PW/BuildineInsnection <br /> A.Property Owner Information <br /> 13tur__ . ��� m5 'l- g( & ii..Cv ek_ 2L tlu x%P, . PZ- __. <br /> Name Mailing Address City,State,and Zip (Area Code)Phone if <br /> T B..Legal Property <br /> on �r <br /> f3lLCOO o2oR a -2 1 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name r A Lot / Block <br /> /� p-7 �/ <br /> 1 t 203 S -A h 5j� t-wiP� alive r!1X.iY Sri+ CJ w. L `3 <br /> Property Address ! J City State Zip Code <br /> 1 Directions to Property: <br /> ' C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [Single Family Residence ❑ Single Family Residence ['Public <br /> 14 Name <br /> Number of Bedrooms Number of Bedrooms gi Private WPC if <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> El Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ElConstruction Permit ElPermit Reinstatement ElReplacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor IN Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other El 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 <br /> Applic ' >\ 'ing Ad ss <br /> 5_ 5-g..,3 201683 <br /> S' ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative 'Authorization to Apply form Attached <br />