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OD.-. 1:5‘. (.P <br /> Application for Onsite For City Use Only: Date Stamp: <br /> —_ 4_ Wastewater Treatment System City of <br /> 11.1 <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 /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A.Property Owner Information Ad `a Q <br /> � lW,i 2/5/P C�d.�/, � L/ aldif C;„ /7/jam 3b3- hO6 7ZL)o <br /> Name Axidpvjf1-t _ Mailing Address / City, State,and Zip/ (Area Code)Phone# <br /> B.Legal Property Description <br /> CsQ AlLe L.Peol O Z WtlO13oa 26.C2 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Oy 2. IA 67 <br /> Sub5yi,App1 me Lot Block <br /> 1 c1,G. ,.po-e, Gz_a_eik. Icove NE a Pc 12 0R t-2 )3 7 <br /> Property Address City State Zip Code <br /> Directions to Property: c-205v ' 2 . A,21...,,r 6raru2 12.4 MclGce.m !a61, s,,,z,ovl <br /> l <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ❑ Single Family Residence ['Public <br /> 1 Name <br /> Number of Bedrooms Number of Bedrooms igl Private A _e/ <br /> ❑ Other Other 4:AR.1"1 ° o Cs+& Spring, Shared <br /> fll-ttryij- D. Type of"Application <br /> t _ Site Evaluationbc,o_ ❑ 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 ?LED Sept:0-rop-Qe�, <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 /> NA 2jc.. ANi)Ee.sO n.) SO2 —,0G 7260 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic. # (if applicable) <br /> 215 71 c LIa.-. .po--e Cr2_0_01, Cane NE.. S-I'. Pa,LS OP 97 /3 7 <br /> Applicant's Mailing Ad <br /> 2/6 Zv23 <br /> Signatu Date: t CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />