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2S—o-O96s1 EogL <br /> ,;_ _, Application for Onsite For City Use Only: Date <br /> Wastewater Treatment System City of <br /> 111111 <br /> Date Received � L� � � � V <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by L- <br /> 5155 Silverton Rd NE Fee L y �1t 1 ) 2 2023 <br /> .• <br /> Salem OR 97305Receipt# <br /> (503)588-5147 Fax(503)588-7948 Activity# MARION COUNTY <br /> "'=-_ ors_, .... :: ;, FT2.:r_e;x =.,_, -- •= r;!1!I D NC4 INSPECTION <br /> . A.Property Owner Information <br /> r..p., uJtk- _tb ex?SI? L•3t4 -.s Di f cc : 97363 . :,°z7—i�3(sz <br /> Name Ms;ling 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 /> (,,-7 Li 0 <br /> n <br /> 4O7 S 4, N\ -Q's- . _gG<--`°,2v-,_ e9 r 9 ' 117 <br /> Property Address 7City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Prieting Faciitty: Proposed Facility: Water Supply: <br /> :Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms .czt Private i.- e' it <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> 4 Site Evaluation ❑ Renewal Permit ❑Aathorizatlon Notice for. <br /> Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> Applicant'sy Mailing Address <br /> 1D t W 11451) tip :117 v a 177063 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative Authorization to Apply form Attached <br />