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.. _ ______. ._„..._ , , _ <br /> . _ <br /> 3cMffl <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> MIMI <br /> Date Received <br /> 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 /> Svww.co,marion,or.us/PW/Buildinglnspection Activity# <br /> A.Property OwnerInformation, <br /> T r t-r 1L1 113 as>-4- arJZ the Sc& e�-- .—L oi& cr-13gt <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> .:Le Pin ' <br /> S� perty.Description <br /> 0c B 1 G f4 4i-ea t6C43 166C) 1,00 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 114I I i4 .la tt1`F— r Itre.lc., Cr? Q173 -7 <br /> Property=Address City State Zip Code <br /> Directions to Property: <br /> C ExistingFacilityI Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> RISingle.Family Residence 0 Single Family Residence ('ublic: c 2. <br /> N e <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> w. .. D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ® Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major El Minor 0 Existing System Evaluation 0 Personal Hardship <br /> O Alteration Permit 0 Record.Review 0 Temporary Housing. <br /> ❑ Major ❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5 yrs old) <br /> {Ade.- t f r^P.lL 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 <br /> Applicant's Mailin dress <br /> ..... J1_22,-Z3 201683 <br /> nature Date: CCB# (if applicable) <br /> Applicant is the❑Owner ''Authorized Representative "Authorization to Apply form Attached <br /> i <br />