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Application for Onsite ii -005 VS-3o- AvT1-1 41).0;„,„z,. pp For City Use Only: Date Stamp: �.-- W.__� Wastewater Treatment System city°f n Date Received, ____1[_ MEM MARION COUNTY PUBLIC WORKS by BUILDING INSPECTION DIVISION . Zoning by JUN 1 3 2018 ---(6 5155 Silverton Rd NE Salem OR 97305 Fee • ARIO COUN- • (503)588-5147 Fax(503)588-7948 Receipt# LIED NG iNSPECTQN6 www.co.marion.or.us/PWBuildingInspection Activity# - _::- - --- A Property Owner Information v _ _ ,. &fav\ga, q40 castitect.,,CC, hue ije 5 a ievA,(\ W 17 ( 3)C)7-12S 6 Name Mailing Address City,State,and Zip (Area Code)Phone# s : B Legal Propertybescnption �" O ^'�`v ' S Q e_ et a,ke. L C, _..._,4.7,0.1 d 7 a lV.du D n 0 1 43—DO I._., " --..__.. Legal Descriptioine h 4- / e..„4„,, F...„.,./.._ Fwr�s Tax Lot Acreage or Lot Size • Subdivision Name Lot - Block . q q0 PAsTv UWh /4()E/J6 ' -elf\ 6 a it 17 Property Address 1 City I St to 9- Zip Code erections to Prop rt-ri-QYI(, k,i0k west" C— ,3 Y at, Fri,(-Yi ) YU.r in ,t r'r 1 i rs o_5c. ov.. ler C Existvig Facility/Proposed Facility/Water;Informat on x Existing Facility: Proposed Facility: Water Supply: VSinglemily Residence )J Single Family Aesidenck ❑Public it ntiz Namie Number of Bedrooms - . Number of Bedrooms .Private ( e)k. 6,01,-.AreD ❑ Other ❑ Other Well,Spring, Shared - D Type,ofApplication Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: Construction Permit ❑ Permit Reinstatement Replacing a Dwelling ❑ Repair Permit ❑ Permit Transfer 196.The Addition of One or More Bedrooms ❑ Major ❑ Minor • ❑ Existing System Evaluation ❑ Personal Hardship ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over 5-yrs old) ❑ 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. ri a,it‘ Ste,' 503 -Sol 12S Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) 940 PAstvec 41,0D tAgE 4E 6ACC—w1, a a73/-7_i_________ i . it's Mailin: _A _.. -ss / 0 moOM."il A. 6_, It,ts-- . ignature Date: - CCB# (if applicable) Applicant•is Owner "Authorized Representative ❑Authorization to Apply form Attached G:\FORMS\SEP I n-11 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18