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S55-2Z OQcT(o$"S- - PRInf
<br /> Application for Onsite For City Use Only: Date Stamp:
<br /> --%._ii Wastewater Treatment System City of
<br /> 11.1111
<br /> Date Received /]
<br /> MARION COUNTY PUBLIC WORKS Received by EC E I v E --- ,
<br /> BUILDING INSPECTION DIVISION Zoning by 1
<br /> 5155 Silverton Rd NE Fee OCT 21 2022 JJ
<br /> Salem OR 97305
<br /> (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PWBuildinaInspection Activity# MARION COUNTY
<br /> BUILDING INSPECTION
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<br /> _ Mailing Address City,State,and Zip (Area Code)Phone#
<br /> jeg I h' - aK. » aT I : TT,' a ? ti ` t Mr Y fTi _ ' - rggTr 0-12. 1-7 00O 2 0 0 2.U-c 3.co-C. A
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> 2-0(6, 7z Iziv 2.e) Nr S�. `.a, .i1 G(L._ 57i' -i
<br /> Property Address City State Zip Code
<br /> Directions to Property: 14/ in; Ahl r 44' c)f S+• PA LA U Lek N U/Y Z 1`\
<br /> fit !C ExistingFac nt StW ;R� , I6 1 1i a1 m3x. T TiN ; ..
<br /> U 1A•4U Existing Facility: Proposed Facility: Water Supply:
<br /> Single Family Residence 0 Single Family Residence ❑Public
<br /> Name
<br /> Number of Bedrooms Number of Bedrooms 0 Private
<br /> 0 Other
<br /> ❑AO twh e r Well,
<br /> ell, Spring,
<br /> pring, Shared
<br /> ,. n., � h Ai _ V ER 9D�11;l_ - ' Mea M P RI=51 _ - _ _ 3'El Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:
<br /> El Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling
<br /> jR Repair Permit El Permit Transfer El The Addition of One or More Bedrooms
<br /> ,Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing
<br /> El 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 /> Coe\I M cKi° 069 (so ) 9/0- 3 )- s---
<br /> Applicant s Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> ---PO Box Co 6, S4-. ?6,u1 6<-- 9 '7 137
<br /> Applicant's Mailing Address
<br /> 7;2/ 1 v f 2- 1 f 2. .
<br /> Signa e Date: CCB# (if applicable)
<br /> Applicant is thewner El Authorized Representative ❑Authorization to Apply form Attached
<br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22
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