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,, s:,,,q_ Application for Onsite For City Use Only: E. <br /> e$mpa- <br /> :�->» Wastewater Treatment System City of l� <br /> r Date Received <br /> MARION COUNTY PUBLIC WORKS Received by q <br /> i r---D 0 12023 <br /> \-1 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee ivl/ ilvi�l r,vUi�!"i`r' <br /> Salem OR 97305 BUILDING iN PE TIUi�I <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnsnection Activity# <br /> A.Property Owner Information <br /> Barbara Jennings 537 Myrtle Drive Monmouth,OR 97361 503-931-6849 <br /> Name_ Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 082W 13-01200 4.82 Acres <br /> Legal Description Tax Lot Acreage or Lot Size <br /> N.A. <br /> Subdivision Name Lot Block <br /> 5375 Howell Prairie RD SE Salem Oregon 97317 <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 /> OSingle Family Residence 117.4 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ S• ite Evaluation ❑ Renewal Permit (Authorization Notice for: <br /> RConstruction Permit ❑ Permit Reinstatement .Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ A• lteration Permit 0 Record Review 0 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 /> Noble Built Homes, LLC 503-932-7698 N.A. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P.O.Box 571, Silverton, Oregon 97381 <br /> Applica ' ailing Address <br /> /-2r— Za-k.2 /C 0 <br /> Sign re Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />