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Application for Onsite For City Use Only:Ci -9HE Date Stamp: <br /> Wastewater Treatment System of CELIVE <br /> Date Received <br /> 1111M MARION COUNTY PUBLIC WORKS Received by MAR 22 <br /> 2U19 <br /> BUILDING INSPECTION DIVISION Zoning by -7 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 C <br /> www.co.marion.or.us/PW/Buildin2lnspection Activity# ( (p2 27 <br /> „A Prope Owner information <br /> rty <br /> 1401)A4 e/D J ( 1./i32 Po t/1 TE QoyAl,6 oi A '?, i? 7- T/7-0,1c-??Ci <br /> c-??Ci <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> ig <br /> , <br /> B Legal Properly Descnpt[on' <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1,-;<j t) ( /AT2j L- 67/1-7"-e3 bit. 9-?-31/6 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> l (6,7(.7;11)-;ti IL-1,5-C. <br /> 3 3 ,,C dstiiFaelli _''P ro 0-§ed Fact. /Water Information' "� ,3� <br /> L ,.�,._�._.�-_ .�_ _�__ ___ ,a. .., _.A�... _.�.g,�,u tYPu... y .��. .� ,.�.a.� ._�...._—.._� a�.---� �.��..... ...__... <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ,Public _64 D P4 o}17=_� <br /> a Ac-P ltule)!JI i Name <br /> Number of Bedrooms // Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D Type of Appltcation ;'' <br /> ❑ Site Evaluation ❑ Renewal Permit gAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ,IN Replacing a Dwelling <br /> ❑ 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 /> ❑ 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 /> 170 L>�F� 71 61/7 /"1A9.c.- 7-95 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> o2TIB=1, Po//l- c— '2 yi tik60AA- f i`.�o6L_ G/4 g;6.--9- <br /> Applicant's Mailing Address <br /> �'� P1 Raid do r 6 aD !� <br /> "_ Date: CCB# (if applicable) <br /> !..01,..07,411.0••-•.:-.111111111111.- <br /> : <br /> Applicant is the,IgOwner 0 Authorized Representative ❑Authorization to Apply form Attached <br />