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r <br /> N, r Application for Onsite For City Use Only: 77yy�� <br /> Nil <br /> �� Wastewater Treatment System city of1-12 <br /> VE <br /> am_ ._; _,. <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by 'if <br /> Q 18 <br /> elo1® <br /> BUILDING INSPECTION DIVISION Zoning by CC <br /> 5155 Silverton Rd NE �i/ hiOi� 1, y� <br /> Salem OR 97305 Fee ���� � { ; <br /> (503)588-5147 Fax(503)588-7948 Receipt# �' CTIO� <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> iti..: ...@. , .,. J , ,..g„:...., A Property Ownei informatton .... <br /> LA-Mat 1----• --- <br /> cov►c= 4- Po. 130x`70S -116.421.-t e 09.- 9139Z 503 G��1 2e33 z_ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> rt e , it , ,f B Legal Prape Descritirion ` ,r ,.., , ,, -,1 ,,,• , <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot• Block <br /> Property Address City State Zip Code <br /> Directions to Property: 11,9 p i°f►ca. i--i--4 S <br /> C EXtstin F`aelht fPro Osed Facih I Water titormatton 'K'` ; <br /> g___._._-Y., 1?—„_, ty <br /> Existing Facility: Proposed Facility: Water Supply: <br /> (Single Family Residence Single Family Residence ❑Public 1J4 <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other digNikpring,Shared <br /> h E ;t r C a r rD 'T e ofA hcatlon <br /> ❑ Site Evaluation El Renewal Permit Authorization Notice for: <br /> E l Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit El Permit Transfer Di The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation El Personal Hardship <br /> E l Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Departures • i ' .. mental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> r� ..b GO SC, S •- 23- <br /> 4.. ,'s Name—Please Print 'egibl: Applicant's Phone Number DEQ Lic.# (if applicable) <br /> • :, .,'s Mailin•,•ddress <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner El Authorized Representative El Authorization to Apply form Attached <br />