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al Le ? 3 <br /> Application for Onsite For City Use Only:y Date Stamp: <br /> = � Wastewater Treatment System city of <br /> A. . � _ <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A Property Owner Information .� _.. 4 , - , <br /> j WW L W4LL/ - -z fo �1 t e,.f. .-- �l✓ �'r7 . " 7 7?- 33 � <br /> Nam Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Property Description, <br /> Legal Description(� ^� Tax Lot Acreage or Lot Size <br /> . /?A/_Feria.J E IJ e I 4!a g P.J^04cEe <br /> Subdivision Name Lot Block <br /> 3.oS /?,, *%S .s- SI L,*,ws 973 S8 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> ................r'.- C Existm gf4cthtp lProposed Facility/Wader InforT4ahon„,; <br /> Existing Facility: Proposed Facility: Water Supply: <br /> f+Single Family Residence Zr Single Family Residence ['Public _ <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private _ <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D T e of A hcation <br /> ❑ Site Evaluation ❑ Renewal Permit ril Authorization Notice 1 : <br /> ❑ Construction Permit ❑ Permit Reinstatement [' Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ® Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 /> 141cl/A 14j,//6-- ,5723- 72 'y30gs- <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> A,9d q ,4ue fe ,s,elL y a .973/7 <br /> Appli ' Mai 'hg Address / <br /> 06-1 - 7��,t' <br /> Sign ure Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />