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, 55S--IE-0631/3�-E VAL- � Application for Onsite ,nw �..41k,,,,„...., � PP For City Use Only: Date Stamp: - *ZWastewater Treatment System City of imi. _.,. . Date Received MARION COUNTY PUBLIC WORKS Received by r P((i C J V , BUILDING INSPECTION DIVISION Zoning by �� 5155 Silverton Rd NE ®4.. p� Salem OR 97305 Fee MAY 0 201 J (503)588-5147 Fax(503)588-7948 Receipt# L I iC Activity# NiAb.ION COUNTY 81 ill n NG INSPECTION A.Property Owner Information 0a9'1.fou.,iGL e7'141. Pa 90x /0/3 M/u.oi>' ee 97360 5'03-9e -673 Name Mailing Address City,State,and Zip (Area Code)Phone#t B.Legal Property Description 6. 7E5,I4 Yif Aj incA/, sttct /pr od' O 3 Z7j,40/lap a 60 Legal Description Tax Lot Acreage or Lot Size 32067 64-7E5 M4eY A-4-3).31770/vr R 57-o I Subdivision Name Lot Block /;-7 641E5 ,Jlu /i> &ATES Og 973Y6 Property Address ("E..4- -/) City State Zip Code Directions to Property: //IVY 22 m 6,4,-re-$ //, /LL A:'.') (.NEherM) pgoisierrr,O ) 4E575-/- C.Existing Facility/Proposed Facility/Water Information Existing Facility: Proposed Facility: Water Supply: ['Single Family Residence ingle Family Residence 118<blic rri/ry of 6.4-1-14-5- 7-1/149 .4'7i'T'lst/O Name Number of Bedrooms Number of Bedrooms ❑ Private O Other ❑ Other Well,Spring,Shared D.Type of Application Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: ❑ Construction Permit ❑ Permit Reinstatement ❑ 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_ MVO< 6,443TcHE TN-231-27/5 -- Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) 2075 tt4, 5-T co/ 5),u- t9iC 9730/ Applicant's Mailing Address , 44/0‘4, --- 4/167/7 — Signature Date: CCB# (if applicable) Applicant is the U Owner X Authorized Representative N.Authorization to Apply fo:S:a Attached ppoT E5 &/li1>¢/G Co.M