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Application for OnsiteFor City Use Only: Date <br /> Stamp: <br /> --==-= Wastewater Treatment System City of <br /> Date Received <br /> MN " 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/Buildinglnsuection Activity# <br /> A Property Owner Information <br /> T� r tok to (0/7 31-9-Fm rsa Tv nfrl ®g- ii 7r SZ -q -`IZgi- <br /> Name) Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description_ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> &Oit 1 St + Y Ld `�r�9r Off- 9 1 3`la <br /> Property Address' City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Famil Residence 0 Single Fauily Residence ['Public ' <br /> �`) Name <br /> Number o Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well, Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit !�A thorization 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 /> -TYO <br /> Applicant's e—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 00/17 SibillA/131() gel se ,---\\AN)Aev\ Cf--- en;_7J9g--- <br /> Ap licant's Mailin Adeipts <br /> ign Date. I CCB# (if applicable) <br /> Applicant is the4'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 <br />