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3-6t)`-1 .--7 7 <br /> RECELIVEFi <br /> ._............... . MAY 19 2023 L. <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> • <br /> Fearttyukoifyi DateStampc <br /> Application for OtiSite <br /> Wastewater Treatment System c491 <br /> I <br /> I'll' DateReceived <br /> MARIONCOPITYMBLICWORKS :: gc°4"4 bY •• <br /> BIBLOINGINSPECTIONOIVISION loping by <br /> SISS SilvettattiRd.NE <br /> Fee <br /> Salem OR MOS <br /> (503)555-510' :Fate(503).588-7948 Receipt <br /> - - • - - Attivityll <br /> • <br /> vilrinuemmarliimai-ait/PW/Buildineinitletti - <br /> • <br /> . . <br /> A.PrOperty 0Vmer tnformatiort. <br /> $4560-0-1 5.Pi!laL4jC://i /CIS:5- Arde..U1 Pr SC4(Q.4evl- 0 r q2eoz .Name Mailiag Address .City.State,andrip (Aran Cede)Phonc# • <br /> B.LegaliFropertyDescription <br /> - . • <br /> Legalt/eseription Tax tot Acmage mint Size <br /> Subdiviaion Name. Lot Block <br /> 0 I IA%i <br /> 1'IV k 3:),ULetA1C) LVV Property Address City State Zip Cede <br /> Direction,stO Property: <br /> C..:EXisting Faeilitr qttipoSedFaeility/Water Informatiim <br /> Existing Flteitity: Proposed Facility:. Water Supply: <br /> OSinele Faint1y.Resitience :Single Family Reoidence OFiblic <br /> 3 :Name <br /> Number of Bedroom; Number of Btalmoma trPrivate (,r.,_, ..,e_..t I <br /> D Other c]Other Well Spring;Shared <br /> D.TypOnfApplication <br /> , <br /> a Site tvaleatien 0:soietsaPeraik 0Authoriutton Notice for:Construction petntit 0 IRcastit Reinstatement 0 Replaeinge:Dftlling <br /> Ul Repair Permit 0'Permit Transfer 0.The Additiotte0aeot More Bedroonxs <br /> 0 Major 0 Minot 0 EtistingSysteptEValuation 0:PerktialHaniship, <br /> 0 AltcrationTermit 0 Record Review El Temporary Beasing <br /> El Major 0 Minor 0 Other CI Catatecting to an ExiSting SyStein Never irt Use <br /> (over 4-yrs old) <br /> 0 Other-,pleaseSp_ccify <br /> . . . <br /> lithe readmit/0'01d attachments are 0th:eluded with this appliedfien.it will be returned toxnt as inconvlete: <br /> Poit the;orangeicard,at.the entrance to the.property.:Flag the tett bales. <br /> By my aignettuva citify that the inforientien thavelinnisherfjaearrect,:and hereby grant Mallon COuntyrautherked'agent ofthe <br /> Deparettent of Environmental'Ouality.pernissiOn blenter mitt)the above descrffied,property:for Meseta parposeofthit.application. <br /> r Cy e cq <br /> e%,0 e.) f3,t-'3c/ <br /> ._._ e , i 9 . : ./8?‘ <br /> Applitaird'aName÷Please Plitt Legibly AppliemiesAcme NuMber DEgLie:#(ifapplicable) <br /> 0 1, NA' - eitst ke 17 e 4-- 10p- 97367 <br /> Applicant'a Mailing Address• <br /> art ' c <br /> /207 ZC1Z_ . . <br /> Signature . ' pate: CCB#(if applicable) <br /> Applicant is the El Owner El Authbrized Represeetative Q Anitiorization.to Appiyfettia Attached <br />