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Date Stamp: <br /> ,, , Application for Onsite For. City Use Only: RECEoyEn <br /> Wastewater Treatment City of <br /> Date Received FEB 04 2019 <br /> IIIIIII System Received by <br /> f1/iARiON OOH! 7 <br /> Zoning by NTY <br /> Marion County Public Works Fee BUILDING INSPECTION <br /> Phone: (503)588-5147 Building Inspection DivisionC1_ <br /> Fax: (503)588-7948 555 NE Court St.,Ste.2260 Receipt# (6 37 <br /> www.co.marion.or.us PO Box 14500 <br /> Salem,OR 97309-5036 Activity# <br /> A. Property ON\ner Information <br /> $\e\1-€ \ U(*me. Mailing Address Phone Number <br /> B. Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size , <br /> Subdivision Name Lot Block r <br /> Property Address:3X-0U '1\9r' .4 \3 (o �U ,k\X <br /> Address City State Zip Code <br /> Directions to Property: (\0,, (loeKs).. k•—\L,``) <br /> C. Existing Facility / Proposed Facility / Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑ Single Family Residence 2' Single Family Residence ❑ Public <br /> 3 Name di <br /> Number of Bedrooms Number of Bedrooms we Private GO <br /> O Other ❑ Other Well,Spring,Shared <br /> D. Type of Application <br /> B, Site Evaluation ❑ Renewal Permit 0 Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 TeHardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temonporary Housing <br /> 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major 0 Minor ❑ Other <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 foe sole purpose of thi a pl.cation. <br /> ��Alif— <br /> Sig0.-H-�{-I 3U VI551 <br /> ature Date <br /> (c ow Afv_0, cau@ vg_WkLQ at :op <br /> App icant's Name—Please rint Legibly Applicant's Phone Number Applicant's E-mail Address <br /> Applicant's Mailing Address U <br /> Applicant is the ❑ Owner FaAuthorized Representative ❑Authorization to Apply form Attached <br /> S-01 3/05 <br />