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/ee d L,61 as <br /> Application for OnsiteCity y: D [ � Y� <br /> For Use Only: <br /> 't"">°�' <br /> =_- -� Wastewater Treatment System city of DECN Date Received C 1 2020 <br /> MARION COUNTY PUBLIC WORKS Received by �VI/�RIO�� �, <br /> BUILDING INSPECTION DIVISION Zoning by O #j��-lr <br /> 5155 Riverton Rd NE ��iL®r(�O INSPECT ION <br /> Salem OR 97305 Fee _ <br /> (503)588-5147 Fax(503)588-7948 Receipt# � (�( <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> A Property Owner Information. <br /> DC_ l.-) e,se i z3 .QorkJlkA-- &cq,05 or 9 23 7/2/ - it i-k {'( - <br /> Name Mailing 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 /> ( 2 2 �: __Ivt t_ (9€S i,V- 19 73 it'(, ' <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 /> ❑Single Family Residence ,E1 Single Family Residence tiPublic (' 1 t~/ <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ;;Site Evaluation Renewal Permit <br /> ❑ ['Authorization Notice for: <br /> • Construction Permit <br /> El <br /> Permit Reinstatement ❑ Replacing a Dwelling <br /> e tr Permit IDPermit Transfer - ❑ The Addition of One or More Bedrooms <br /> ajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review — ❑ Temporary Housing <br /> ❑ Major El 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 /> &AiS ,S®.- V3- 71S-7 37e-x7� <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number -� , DEQ Lic.# (if applicable) <br /> �77 O C - C Ji it /tl✓-c4 oc ,9 lAh <br /> Applicant's Mailing Address <br /> \ euJbJu� 4 la-Ult./6 <br /> Si ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 'Authorized Representative 0 Authorization to Apply form Attached <br />