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J • �, ,ii/ Application for Onsite Dair Stam : pp For city use only: Wastewater Treatment System City of D C ED V ` Date Received MARION COUNTY PUBLIC WORKS Received by APR 012019 C BUILDING INSPECTION DIVISION Zoning by 7 5155 Silverton Rd NE Fee MARION COUNTY Salem OR 97305 BUILDING INSPECTION (503)588-5147 Fax(503)588-7948 Receipt# 19 7 www.co.marion.or.us/PWBuildingInspection Activity# -0;b2:375— '`�`" 3 ___ ' —._ L A.Property Owner Information 1e tv,4)LJelkec 158786-esc.6ar LSE Su,bl,rr 10K. g13f5` 503-5-053-5153 Name Mailing Address City, State,and Zip (Area Code)Phone# B. gal Propertypescrnption f. '. 9013,-om.peorce'13 — — LeDict E30 pleb'?, D 64�cre_s Legal Description Tax Lot Acreage or Lot Size 7111' - hiA h/1' . . Subdivision Name Lot - Block . 1 S e.14 Gesc-Ver \--Irk SC StAlz.1-trrvall OK ct i 3 g5 Property Address City State Zip Code Directions to ro erty: 1-lw t)).'EaS - o 'Vt,`rn R .i'1'w(' .ltd-(So,,cho,1.err'�e►N. 1 r/ A�kkPa w�4) kt(044-) D VX Coo WI1 f°\VoL.) l l k a r• - vw•‘So,n -(S o N,Y4`) 1 1 tt-5t-v v.(4+e-S ll.e.f C L i-S -. . a Existing Facility/Proposed Facility/Waterinformation Existing Facility: Proposed Facility: Water Supply: 'Single Family Residence r211 Single Family Residence ❑Public Name Number of Bedrooms Number of Bedrooms RI Private • ❑ Other ❑ Otherg, S rin Shared P D:,Type of Apphcatan..::..._ ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: ❑ Construction Permit ❑ Permit Reinstatement . I Replacing a Dwelling ❑ Repair Permit ❑ Permit Transfer ❑ 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. -1\--ct h,e, k)el4er '5o5-Ste-S163 . Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) t 5$.1-g (1e.S4 .1,1- 1-rY SE .1 Si4.b<<v~ 4.-i , oz 611 3gr Applicant's Mailing Address Si ature Date: CCB# (if applicable) • Applicant is the 0 Owner ❑Authorized Representative ❑Authorization to Apply form Attached G:\FORMS\SEPTICIS-01 ONSUE APPL SEPT 2018.DOCX Rev 1/15,3/18