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a3-6O b Application for Onsite For City Use Only: Date Stamp: ;_ Wastewater Treatment System city of MIII Date Received D �� l I! MARION COUNTY PUBLIC WORKS Received by BUILDING INSPECTION DIVISION Zoning by ! 5155 Silverton Rd NE J U N 30 2023 ij Fee it_; Salem OR 97305 �' (503)588-5147 Fax(503)588-7948 Receipt# MARIO V COUNT'i www.co.marion.or.us/PW/Buildinglnspection Activity# BUILDING INSPECTION 1 A.Property Owner Information: , 1 '5)- S<Ie✓rt 7 41ejr Adon.I9 Cl►•tcl, Name Mailing Address City,State,and Zip (Area Code)Phone# _ - B.Legal Property Description 072w Zl 03300 ' Sy Legal Description Tax Lot Acreage or Lot Size Subdivision Name Lot Block 5575- g.,.-)- i,,,,,/ iaa Nr s4.1cvr, on Q 7317 Property Address City State Zip Code Directions to Property: F "o wl G ordotn Pot d C e✓1 kis h e c of e<SJ , C e n is r . . 'a" J yid �rul-)e.A re), air,ii vii de i.. 7nhl 0l1 daf1-1-% 3•GIL G3's roc. - , C.Existing Facility/Proposed Facility/Water Information _ , Existing Facility: Proposed Facility: Water Supply: ❑Single Family Residence ❑ Single Family Residence ['Public Name Number of Bedrooms Number of Bedrooms Private Wt..}1 (-0 AOther G V‘v't d..l.% 0 Other Well,Spring,Shared -- D.Type of Application Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling /_ Re air Permit El Permit Transfer El The Addition of One or More Bedrooms Major El Minor El Existing System Evaluation El Personal Hardship ❑ Iteration Permit ❑ Record Review ❑ Temporary Housing ❑ Major ❑ Minor El Other El Connecting to an Existing System Never in Use (over 5-yrs old) Z 5 0 5��.A- C\v,r�,^ El Other—Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. v— 64.rdhr,� y 3 503- 32. OvaY 9 Z31 ' 3'153) Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable Sc zy g )<,k 1(lei,'1k c4, ME S4IC kV) , d2 g7317 Applicant's Mailing Address LI 1-, (5.-_1 ( Z 3 �-2 Z 1 6 5-8 V8 Sign a Date: CCB# (if applicable) Applicant is the El Owner Authorized Representative El Authorization to Apply form Attached