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„, ,,,,, Application for Onsite For City Use Only: Date Stamp:
<br /> — -3 Wastewater Treatment System City of •
<br /> IIIIII
<br /> Date Received
<br /> MARTON 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 /> ww.co.marion.or.us/PWBuildingInsnection Activity#
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<br /> Name Mailing Addresh City,State,and Zip (Area Code)Phone#
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<br /> 1141}P�`/O5F 0Z D/40 3800 Co�.°/aZ907/20 Arm /'9,�6� 3Srx)co'
<br /> Legal Description Tax Lot Acreage or Lot Size
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<br /> Subdivision Name Lot Block
<br /> / 5-0 S7Yrk4rri i) r- 0 1 0)2. C73Y7_
<br /> Property Address City State Zip Code
<br /> Directions to Property: 7 k k sn.11 it,y 2)r I i-e d 14' 1-rw>a L
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<br /> Existing Facility: _ Proposed Facility: _ .. _. Water Supply: ((`` -
<br /> ❑ ingie Family Residence ,� Single Family Residence Public (�' r)-y Q4 �deoi i
<br /> @'-t-t'h6 V-�d+ Name
<br /> Number of Bedrooms Number of Bedrooms ❑ Private
<br /> ❑ Other ❑ 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 /> C! e e.•' Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms -
<br /> __ E1 Major •❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> all Alteration.r Permit ❑ Record Review' ❑ Temporary Housing
<br /> 2 Major ❑ Minor ❑ 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 testholes.
<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 urpos of application.
<br /> Yo i ,sC-v,1fr� i LCC'
<br /> T)IY-‘) N, . . Spa VkS • 3-03 —gSq 7 0 3galy,�-
<br /> Applicant's Name-Plee Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> 7Q0 ( gi;$2 - A612vklow !-A7 02_ 773b1
<br /> App ' is Mailing Addres ,
<br /> /7 ' --20 2: 3 ,
<br /> i tore Date: CCB# (if applicable)
<br /> Applicant is thgwner ❑Authorized Representative ❑Authorization to Apply form Attached
<br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22
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