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23_. W(ZL INQ4
<br /> Application for Onsite For CityUse Only: �'n'�-'� z
<br /> p:.illhank o
<br /> :?g' Wastewater Treatment System city of �j z
<br /> c�
<br /> Date Received >1111111 a
<br /> MARION COUNTY PUBLIC WORKS Received by ' O CA
<br /> BUILDING INSPECTION DIVISION Zoning by J� U
<br /> c''D Z
<br /> 5155 Silverton Rd NE Fee 0 ›.- U 0
<br /> Salem OR 97305
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.onus/PWBuildingInspection Activity# ��
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<br /> Name Mailing Address City,State,ana Zip (Area Code)Phone#
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<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> $Co Kern D;a vrna v.1,�,
<br /> Subdivision Name Lot Block
<br /> 13/83 f icGr& Q1 SE- i t rve.d- 0& 473q 2
<br /> Property Address City State Zip Code
<br /> Directions to Property:
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<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> �ingle Family Residence Single Family Residence ['Public
<br /> 3 3 Name
<br /> Number of Bedrooms Number of Bedrooms Private J e,11
<br /> O Other 0 Other Well,Spring, Shared
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<br /> Site Evaluation ❑ Renewal Permit ['Authorization Notice for:
<br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms . .
<br /> ❑ Major '0 Minor 0 Existing System Evaluation 0 Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing
<br /> 0 Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> 0 Other-Please Specify
<br /> If the required fee and attachments are not included with this application, itwill 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 /> Zac lnacy 1 oine Y 5G3-50-t-Lt544G.
<br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> 132-83 ?lca:A e1 SE Tuty� 1 OK l 'II3`t2—
<br /> Applicant's Mailing Address
<br /> A -5—;v1 5/3i / �3
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached
<br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL DULY 2022.DOCX Rev 1/15,3/18,6/22
<br />
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