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• • • • f Application for Onsite For"h�„�. �t' CitpUse Only: Date Stamp: - • • , � Wastewater Treatment System City of Date Received :MI MARION COUNTY PUBLIC WORKS • Received by • _BUILDING INSPECTION DIVISION Zoning by • 5155 Silverton Rd NE Fee • . Salem OR 97305 • (503)588-5147 Fax(503)588-7948 Receipt# wlirciw.co.marion.or.usfPWBuil din gins pection Activity# k Property Owner Information • Ri cijato� 1L ( 7 33S •foz,NO 11 ev. 9730 s. (903)67o-615e Name Mailing Address City,State,aid Zip •(Area Code)Phone# • B.Legal Property Description • 7119 7 Aµ/ o A • . • G.�32-4-e-1�-E5 - . Legal D escription • Tax Lot Acreage or Lot Size 4 Subdivision Name Lot Block • • • I° - 3 51.1i..,,e4.._ led 067- • St lam. 4.0dL • 973 0/ ' Property Address City State Zip Code Directions to Property: - • C.Existing Facility/Proposed Facility/.Water Information - Existin.g Facility: • Proposed Facility: Water Supply: • ❑Sin gle Family Residence ❑ Single Family Residence ❑Public - Name Number of Bedrooms Number of Bedrooms ❑ Private - El•Other • ❑ Other • Well,Spring,Shared. . • - D.Type of Application • ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: ❑ Construction Permit ❑ PeimitReinstatement ❑ Replacing a Dwelling ❑ Repair Permit • ❑ Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System Evalnation ❑ Personal Hardship • ❑ Alteration Permit ►:l►Record Review ❑ Temporary Housing ❑ Major ❑ Minor ■ Other ❑ Connecting to an ads. ting 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. (4414 ; • • . : (603)4/3 0 -7!-4S ' Applican Name—Please Print Legibly A licant's Phone Number DE Lie. (if applicable)PP Q # apph abl ) DISI 3b57 te!giltM-1u- n- 7317 . - Applicant's Mailing Address • - • . . • • • : All,1 • Z/ /// • • • . • Signature Date: • . . . . CCB# (if applicable) . Applicant is the 0 Owner N Authorized Representative 0 Authorization to Apply form Attached .