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2g - 0-06I/ (3 Puri <br /> Application for Onsite For City Use Only: Date Stamp: <br /> lie <br /> =• Wastewater Treatment System city of E V <br /> p <br /> - Date Received RE <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by till 2"7 9n?3 <br /> 5155 Silverton Rd NE <br /> Fee <br /> Salem OR 97305 TY <br /> (503)588-5147 Fax(503)588-7948 Receipt# UI gBlON COU INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection <br /> Activity# BUILDING INSPE <br /> ... .:' A'Properly Owner Informatron,, ...,_ . ..,�__..,. _ , ... <br /> Nam6 Mailing Address <br /> Cy,State,and Zip (Area Code) one <br /> _ . 1 . . 1 . ' B e 40_51. '.044s.aigk . .. , ^ . ._ . . . <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address i City State Zip Code <br /> . Directions to Property: IS 0 6 tva oa 1 r- 6 C) f: -40-1 .0 6 <br /> C Existing Facility__/Proposed Facility'/Water Infor nation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> {Single Family Residence 0 Single Family Residence OPublic <br /> II Name <br /> Number of Bedrooms Number of Bedrooms j Private .,G 1 <br /> ❑ Other 0 Other Well,Spnng,Shared <br /> yp PP �t <br /> _, � D T e of A hcation , <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ' Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> NMajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> I !_Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> i 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 /> -P\ F1(_,0,i-)n.'1 ) �1(.A ,; ;)?,�?, N, c <br /> Applicants Name—Please Print Legibly J Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Ap• .cant's Mailing Address i <br /> *ak‘aii4 fn --7/7.:c/7,3 L--\LA 5'c-_)\ <br /> Signature �t / 4)14 Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />