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z3 s �NC,25 EvPil—
<br /> ,,, k. ,7. Application for Onsite For City Use Only: DatL 0
<br /> %:=ii Wastewater Treatment System City of • N
<br /> Date Received fat _`_ �
<br /> MARION COUNTY PUBLIC WORKS Received by nn ev '
<br /> BUILDING INSPECTION DIVISION Zoning by -'�I _`
<br /> 5155 Silverton Rd NE `'
<br /> Salem OR 97305 Fee ",..._� (.' `_
<br /> (503)588-5147 Fax(503)588-7948 Receipt# _, <
<br /> www.co.marion.or.us/PWBuildinSInspection Activity# p
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<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> $co I« D:c,-v+n44.4
<br /> Subdivision Name Lot Block
<br /> 133g5 -
<br /> -4244 Qlc- '& Q1 sE- i v,,cve.st QC ct731 Z
<br /> Property Address City State Zip Code
<br /> Directions to Property: .
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<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> single Family Residence IdSingle Family Residence ['Public
<br /> 3 3 Name
<br /> •
<br /> Number of Bedrooms Number of Bedrooms A Private 1.JeAk
<br /> ❑ Other 0 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 /> ❑ 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 ❑ 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 /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> I3Z93 f iCas2 e1 s . �'u INNS r Oft { �.?3C
<br /> • Applicant's Mailing Address
<br /> A --6 a 5/3 I /�3
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the Owner ❑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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