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<br /> Application for Onsite For City Use Only: Date stamp:
<br /> ----------Tigi Wastewater Treatment System City of
<br /> Date Received
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<br /> MARION COUNTY PUBLIC WORKS Received by t ' _. ,. LI V E [11
<br /> BUILDING INSPECTION DIVISION Zoning by
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<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 Fee NOV 2 2. 2022 —/
<br /> (503)588-51.47 fax(503)588-7948 Receipt#
<br /> Activity.#
<br /> www.co.marion.or.us/PW/Buildinelnsnection MARION :;OUNTY
<br /> ,. BUit..DIN__, it•\,tSPECTION
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<br /> E05-i-e-' 4 A cv r•t• tAl'e- 11) 81 Eitl 1/4.thy tai_.5/- ' h.?-r•Yleo• , 0 R. el 7 5 9'Z. -563-8 Ihi.---.353.5-
<br /> Name Mailing Address city,State,and Zip„,.._ ,,,•,.,, (A79919) ?4!#
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<br /> Legal Desci iption Tax Lot Acreage or Lot Size
<br /> Subdivision Name LOt Block •
<br /> 6)88 VAlity Wc_3 -Sr o it '373 /2
<br /> Property Address City State Zip Code
<br /> Directions to Property:
<br /> C;,,E:ififijig:#0:Wk#Kcipoje46Fiii:4':1::wohip:',.-.4 .7,:t--, .,;:'5:7-
<br /> Zing Facility: Proposed Facility: Wafer Supply:
<br /> Single Family Residence 0 Single Family Residence [(Public
<br /> 4+ Name
<br /> Number of Bedrooms Number of Bedrooms Private V\.)c_t 1
<br /> a Other X Other S H0?-1\10 eirn Well,Spring,Shared-.-7------.jinZ;;71, --Z...'7''aF-4-.7..- ,...;:--L7;.7.7.,-t,,,,.-4-i;:zj5Titiiii;o't-Yilpasii4Z- -'''::,,-Tf-,'zT:fFf,tf?-F
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<br /> 0 Site Evaluation 0 Renewal Permit 0Antitorization Notice for:
<br /> 0 Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling
<br /> 0 Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms
<br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship •
<br /> Alto -'eon Permit 0 Record Review ci Temporary Housing
<br /> II: Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> $ Other--Please Specify:
<br /> _S 1 op 13 ta-A J., re I oca te 4-4"k i o vvI,1- u??,.., 2 t..ics A n d re_to c a k 3o bz4-1--g-.91
<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 signatiEe,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized**of the
<br /> Department ofEnvironmental Quality,permission to enter onto the above descrind property for the sole purpose of this application.
<br /> Kt vx elOcatt- Et.e,%.k..-t.g" 50.3- q es 2-osoe y 3 9 2 3 /
<br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> f3C124/ 13 1,,t.lAt„k <-1- SE Sk lf," / 0R 9-73, 2
<br /> Applicant's Mailing Address
<br /> I 6 58 Ye
<br /> turd':).- ------ Date: CCB# (if applicable)
<br /> -:,
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<br /> Applicant is the 0 Owner -Authorized Representative pl Authorization to Apply form Attached
<br /> FAFORMS\SEPI1C1S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22
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