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023-bb5b.1,1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ~` - Wastewater Treatment System City of <br /> Date Received M <br /> MI MARION COUNTY PUBLIC WORKS Received by EcEllyE <br /> BUILDING INSPECTION. DIVISION Zoning by D <br /> 5155 Silverton Rd NE Fee 2 2023 <br /> Salem OR 97305 Recieipt# I Q 1�I <br /> (503)588-5147 Fax(503)588-7948 Actvity# gUILDIN�IN OUNTy <br /> www.co.marion.or.us/PW/BuildingInsnection SPECTION <br /> . A.Property Owner:Information <br /> AANteh 5c,,Poe 1q( Sh..4- -..( recA J' S 4.f�...-. 042. 'c `7 goS— <br /> Name Mailing Address City,State,and.Zip (Area Code)Phone# <br /> . B.Legal Property Description <br /> O 6 21. ) l 6-6o 6(610 4100 S'''. 'Z <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block. <br /> 'tCif 61-> 4 c ( t3e-. ra S.,, o rz cl-73 " <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 ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms M., Private Wit <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application: <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> [54 Repair Permit ❑ P• ermit Transfer D The Addition of One or More Bedrooms <br /> ►:+ Major ❑ Minor 0 E• xisting System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 R• ecord Review 0 Temporary Housing <br /> ❑ Major ❑ Minor 0 O• ther . ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> gap( _ -e yJ c j r s k4--1 0 Other—Please Specify <br /> If the required feeeand 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 /> Applicant's Mailin Ad ass <br /> —(9—23 201683 <br /> Si Date: CCB# (if applicable) <br /> Applicant is the 0 Owner leAuthorized Representative 'Authorization to Apply form Attached <br />