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dt9_Dit(Abljii <br /> : <br /> Application for Onsite For city Meanly: flat.stamp: <br /> Wastewater Treatment System ', CitYar-------- <br /> , Date Received CE - VED <br /> Man <br /> ni <br /> MARION COUNTY PUBLIC WORKS ' Received by <br /> BUILDING INSPECTION DIVISION ", Zonin l',bY <br /> $155•Silverton TUNE- : - NOV 2 9 2022 <br /> ' Fee <br /> Salem OR 97305 <br /> (503)583-5147 Fax(503)588-7948 <br /> ns/PW/13uRditAt.prinospocrwecti,ovato.otH InfARoceecrrnatitiviPittYlit:—____7_5171M1 LADRI NI°GNINCPUENCTYTI ON <br /> ,'. <br /> A 541,1 r ,,.. ..-- <br /> •_?Ot. ...s .c.0=_,,Erst ; t , 0:_5 , -29i2( .6,, <br /> Na e <br /> Mailing Address T City,State,and Zip (Area-Code)Phone# <br /> B.Legal Property Description <br /> Legal Description <br /> Tax 1-ot Aet—:------•------cage or Lot Size <br /> Su 'vision Name Lot <br /> 131ock. <br /> .. .,i_c___ <br /> Property Address <br /> City <br /> SWte Zipeotle" <br /> Directions to Property: i <br /> C Existing Facility/Proposed Facility/Water Information <br /> Foisting Facility:. <br /> Proptised Facility: , <br /> Water Supply: <br /> 0Single Family Residence al-Single Family Residence 0Public <br /> Name <br /> Numbe.-- 1,,7-----'Bedreoms Number ofi.-TZ---froonts ' <br /> l ErPrivate t-A2X... 1..,\_ . <br /> 0 Other <br /> _____________ 0 Other 1 <br /> Welt Spring,SIthsed <br /> D.Type of AppBcation <br /> 0 Site Evaluation 0 Renewal Permit E3Authorization Notice for: <br /> ..construction Permit 0 Permit Reinstatement0 Replacing a Dwelling <br /> 0:Repair Pet-tuft 0 Permit Transfer :: CI The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation ID Personal Hardship <br /> 0 Alteration Permit [3 Record Review '.: 0 Temporary liousing <br /> El Major 0 Minor 0 Other <br /> 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> .': 0 Other-Please Specify <br /> Yule reauiredfee and attachments.are not included with this application:,it will be returned to you as incomplete. <br /> Post the eani at the entrance to the Pro e . Fla the test holes.By my signature,I catify that the information I have furnished is <br /> and hereby t . . t of <br /> gran,Marton County,authorizednen o e. <br /> Department of Environmental Quality Permission to enter onto the aboveldescribed property for the sole purpose of tins application. <br /> C-Oti r <br /> Applicant's Iklarne-Please Print Legibly Applicant's Phone Number <br /> DEQ 1.1c.iabie) <br /> Applicant's Wiling Adclrets <br /> /0 . ..5- e_ <br /> Signature Date; , CCB# (if applica-------gi;T"----. <br /> Applicant is the 0 Owner Ei Authorized ilepresentative 0 Authorization to Apply form Attached <br /> ''.. <br />