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A lication for Onsite For C5 Use O : VI <br /> N' Date S <br /> 1 _ Wastewater Treatment System City of = M( <br /> '11 ~�� Date Received �' .D yr <br /> _ MARION COUNTY PUBLIC WORKS <br /> Received by t; C <br /> xi 0 <br /> BUILDING INSPECTION DIVISION Zoning by Z ~' <br /> Nil <br /> 5155 Silverton Rd NE -Fee 0r___, <br /> Salem OR 97305 ' <br /> (503)588-5147 Fax(503)588-7948 Receipt# 'I CUM <br /> �nn <br /> www.co.marion.or.us/PW/BuildingInspection Activity# U u <br /> A.Property Owner <br /> (503)588-5Z <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <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: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> C!Single Family Residence II Single Family Residence ['Public <br /> 2 iff 3 Name <br /> Number of Bedrooms Number of Bedrooms [1 Private WY-1( <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> epair 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 El Other Idp„c.e.st1r 7 ❑ 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton, OR 97381 <br /> Applicant's .ail.•1 ddr.. _ <br /> r&!l 1 201683 <br /> Sit,'.tore Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ®Authorized Representative 0 Authorization to Apply form Attached <br />