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Application for Onsite For City Use Only: Date Stamp: <br /> %�� Wastewater Treatment System city of <br /> iii,_ Date Received D I E C E l:/ <br /> MARION COUNTY PUBLIC WORKS Received by n <br /> BUILDING INSPECTION DIVISION Zoning by _ AUE 03 2023 <br /> 5155 Silverton Rd NE Fee <br /> SalemOR97305 MARION COUNTY <br /> Receipt' (503)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTION <br /> w ww.co.marion.or.us/P W/BuildingInspectiori <br /> A Property Owner Information <br /> p�ls:Ck Pa4-1e cam, Pc, Rai( 1629 Pew/ eR 477e1 Szit® 'Pig-074'f <br /> Name Mailinng Address City,State,and Zip (Area Code)Phone# <br /> c/ B Legal Property Description _ . _ . °. . :. _ <br /> . k � _ .S?c 2a T i R..cj LI, .' ._ hg 2‘✓7e/t r,6 t Roo <br /> Legal Description Tax Lot i 1566 Acreage or Lot Size <br /> Subdivision Name . Lot Block <br /> Li 5c) 1-1..),-)e_ ram, Ln(cgs- <br /> Property <br /> Address City State Zip Code <br /> Directions to Property: P er-i-3, ii 1:r t lic., - rt" kefa itoq Z- ®e- t �r-' ley se <br /> MC) �IGQe- S c r.lee 4; LI9�0 �'Y fl .c)C - CA' se- <br /> == C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence %.,Single Family Residence ❑Public <br /> L, Name <br /> Number of Bedrooms Number of Bedrooms k Private V-V,/ <br /> El Other ❑ Other Well,Spring,Shared <br /> - " D Type of Application <br /> t: Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major El Minor El Existing System Evaluation El Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Depai tment of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application.- <br /> ) <br /> 12) <br /> Applicant Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Ai) 'cant's Mailing Address <br /> U (-3Pifff :\ <br /> Signature I Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />