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2 3 - 0-0 Co' o`7 40-4 <br /> Application for Onsite For City Use Only: E c \IV SEP 0 <br /> �; ,,Y- City of <br /> —=--..f4 Wastewater Treatment System <br /> 1111111 <br /> Date Received � <br /> MARION COUNTY PUBLIC WORKS Received by AUG 0 9 2023 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING NSPECTIO� <br /> www.co.marion.or.us/PWIBuildingInsnection Activity# <br /> too"��''___M-;-;i-:=�:_�--��it<:=:�°;�-_; 1 _ OR:.:.:.:.:.=:=:= <br /> Bcent Klop enyte,a 113Lis 'oe'5ceen I'N " Si'lvrerhor, C51( 473j1 1503) 2(),a l36-9 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> .0entit-11Ma',0§Wilia'8E- WRIF .45gf;;5IKE4:41tP7i445:440407600110-10Z-gg:OktaSAK.;;: iNctOgilkIl <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 113Li5 Everreen ) i)L �1 <br /> S;IVerICC,n (aR 72Wi <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> _ 1 <br /> - _ - - Extstirl ili 1 Pr: .ed: - -- -- - <br /> .,.. .>_Wit.-- ,...: <br /> o' s :a 'er_ -i�� <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence (21 Single Family Residence DPublic <br /> D. 3 Name <br /> Number of Bedrooms Number of Bedrooms ® Private Li e,11 <br /> ❑ Other 0 Other Well,Spring,Shared <br /> - _- 'FX - ---_- -__- -_-- ---- - _- _ - - -_-- _ __ -- - - --- _--- <br /> ❑ Site Evaluation 0 Renewal Permit [,Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement I] Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 1i The Addition of One or More Bedrooms <br /> O Major 0 Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other Cl 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, 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 /> Brent 11)r)life'ls+t'iil SO3 302 )30 Ll <br /> Applicant's Name-please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> liVIS FvrP ceel I;r) AlE S11Uep n CAR 973Y1 <br /> Applicant's Mailing Kddress <br /> . � i 7- a)- - a3 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br /> F:\FORMS\SEPTICIS-0l ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br /> 1 <br />