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-: A5-j't65 qs ) <br /> dllk4g111' Application for Onsite . For City Use Only: Date Stamp: <br /> -- ;-�i Wastewater Treatment System City of <br /> mi <br /> Date Received <br /> O MARION COUNTY PUBLIC WORKS - Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> : :---- - ,A Pi-dimity OWner Infoririation = . <br /> 2._�# /7 j J 11C)' L Zafg ro/LI. ,e _%3 g57 9r00 <br /> Name Mailing Address City, State, d Zip (Area Code)Phone# <br /> B.Legal pryjoelv Descri�honi_ _._ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> /O 2-3 q rig nlgi ��5t Z.yoN_c 04_ 9?_ <br /> Property Address City ^� Staten ,/� Zip Code <br /> Directions to Property: ��`� Z (i2. S'% / E'` f j Gz y <br /> C Existing Facility/Proposed Facility/WaterInformation <br /> Existing Facility: Proyosed Facility: Water Supply: <br /> [ _`Angle Family Residence D Single Family Residence ❑Public <br /> �'3 Name <br /> Number of Bedrooms Number ofBedrooms [Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> O 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 ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other S',i J277� ❑ 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 /> KA A Al LA CL kI JER ems._6 7- - VC) <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 230et7 t6 op✓---,e LQ,‹/ yous 69e_ 9235 <br /> Applicant's Mailing Address ` <br /> i(ct X ac--1622A-- (6'w 25 - 202� . <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the❑ Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:WORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />