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RECEREF <br /> Application for Onsite For City Use Only: Da P -J <br /> � Z Wastewater Treatment System City of JUN 26 �Z0 I <br /> Date Received MARION COUNTY <br /> �� <br /> MMARION COUNTY PUBLIC WORKS Received by BUILDING INSPECTION <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 /> •�-.r www.co.marion.orms/PW/BuildingInspection, <br /> # <br /> Ci ) -sue,`•. f ..p .. - li `.:6i ` T' , c* t;7F,3 " 'RF Z <br /> 'sd� >� ..�q :�i- ... `�_. �T�':r1k,.+�� .Tw-��" .�i.•�w.-tII11�0III ShOIl 3 �:�L. 7� :"� t�_�.s._.j.���:3'1�>Z:;4'-'4.:1 <br /> tiliN Stb S Wiz. MI \ ' <br /> Name Mailing Address_ City,State,and Zip (Area Code)Phone# <br /> i� -Z ZT—c*-'F"' 7 %' rwwi, '.g. a:T; : T Vflo.TyW'W':�ti�GY N4Z ,.,Igi s , -t1 <br /> c�w�`s �' .��, �_ �-.. ems';.. � ..� ti _� ' � OJ3��-i'� �' *�x.- y.�' age= �,, L.- - <br /> bSI Q Oct'o�l:2 3 C— 00 303 - S %� <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> SOSo .--:'<\t\J3OoC Or City _�2 _ C\-'J�b <br /> Property Address State Zip Code <br /> Directions to Property: <br /> Existing Facility: P <br /> roposed Facility: Water Supply: <br /> Lgie Family Residence Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms El Private <br /> O Other ❑ Other _ Well,Spring,Shared <br /> - ;T . <br /> . s.' .-Ti r3.F��' all4P-cg? z � i ___ is a <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> 0 Repair Permit ❑ Permit Transfer ❑ T• he Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation ❑ P• ersonal Hardship <br /> ❑ Alteration Permit ❑ Record Review El T• emporary Housing <br /> ❑ Major ❑ Minor ❑ Other g 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 /> P o , E.o,c citi m,.L\ c tt O( 92300 <br /> Ap. 'can's Mailing Address 7 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative [Authorization to Apply form Attached <br />