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; P3 / ?PM ( <br /> ' d <br /> Z �:� Q <br /> �„ :�_ . Application for Onsite For City Use fluty: �..r c.P 4 !! u ii <br /> Ci of - --1 <br /> Wastewater Treatment System <br /> ty <br /> y Date ReceivedOM C n�n"1 <br /> � �i <br /> NIARiON COUNTY PUBLIC WORKS Received by 0')0 r <br /> f)IINSPECTION DIVISION Zoningb <br /> 17 <br /> BUILDING <br /> Y c <br /> 5155 Silverton Rd NE •fl"l <br /> Salem OR 97305 Recei t# �;' 1i <br /> p(503)588-5147 Fax(503)588 7948 I ( <br /> "(:(r-. - stk i4 f r -g ---. t t ?.? 11.tf .it.,..c,.r;n A�tivrty# 2 <br /> A.Property Owner Information <br /> n1,"A2C7/ 7 i,'rs-f1 L,LC / //, ig'c ii'r� (Af , 1ei/`l ale 9 - 5 (. j3)9?.�?'76 y <br /> Name Madill• 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 ZGI `Y' 0 A, / Lo Block <br /> Property Address j City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility t Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence g Single Family Residence ❑Public <br /> 6 Name <br /> Number of Bedrooms Number of Bedrooms Private 1� -( <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ICSite Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ", Alteration Permit 0 Record Review 0 Temporary Housing <br /> Major ❑ Minor 0 Other 0 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 % r fi_s <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applilble) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> pplicant's Mailing Address <br /> -- 'l a as 177063 <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the 0 Owner ,,Authorized Representative 0 Authorization to Apply form Attached <br />