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Application for Onsite For City Use Only: ( EP V <br /> M <br /> D (—,_V <br /> _tiuiig-----.-----L- Wastewater Treatment System City of LJ <br /> Date Received m ,E, <br /> MARION COUNTY PUBLIC WORKS Received by MAR 07 2019 LC <br /> 7 <br /> BUILDING INSPECTION DIVISION Zoning by MARION COUNTY <br /> 5155 Silverton Rd NE Fee BUILDING INSPECTIO <br /> Salem OR 97305 <br /> N <br /> (503)588-5147 Fax(503)588-7948 Receipt#Activity# 19- 0 17 19 <br /> www.co.marion.or.us/PW/Buildin2Inmection <br /> A.Property Owner Information: <br /> LV1 01. 1. ���', : ill_ ,. I <br /> Name Mailing Address City, tate,and Zip (Are ode)_Phone a one <br /> B Legal Property Description - <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> \L-111 -A. A__c - 5 3.-\' - <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> - C.Existing Facility/Proposed Facility/Water Information . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence NIPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application r_ _:._ <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> -.1 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 /> El 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 /> '- \\ c O\ 3 SLS au� Q1Ckcc <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> plica is Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ❑Authorization to Apply form Attached <br />