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1°I-t5631-A1� , ;„N, Application for Onsite 'I kFor City Use Only: Date Stamp: - ;=�: Wastewater Treatment System `qty°f Date Received REC--EVE ' MARIONCUUNTI'PUBLIC WORKS Received by BUILDING INSPECTION DIVISION Zoning by MAY 10 2019 5155 Silverton Rd NE Fee Salem OR 97305 MARION COUNTY (503)588-5147 Fax(503)588-7948 Receipt#` BUILDING INSPECTION www:co.marion.or.us/PWBuildingInspection Activity#, _ - A Property Owner Information � _ _ Mark & Jolly LLC 4194 71st AVE SE Salem, OR 97317 503-585-9835 Name Mailing AddressCity,State,and Zip (Area Code)Phone B.Legal Prnpeits Description;__: ACRES 27.92 092W11 01400 27.92 Legal Description Tax Lot Acreage or Lot Size Subdivision Name-air-106. Lot Block 101 7-et 1 L�`Ir Turner OR 97392 Property Address. City State Zip Code Directions to Property: 0.3 miles south of Pleasant Grove RD SE on the west side of Brick Road C.Existing Facility[Proposed Facility/Water Information„ Existing Facility: Proposed Facility: Water Supply: gle Family Residence ,V. Single F�tnily Residence ❑Public `%J� Name Number of Bedrooms Number of Bedrooms Private 12Other ❑ Other .Wel$ ring Shared D.Type ofApplication Site Evaluation 0 Renewal Permit ❑Authorization Notice for: ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System.Evaluation. 0 Personal Hardship ❑ Alteration Permit ❑ Record Review 0 Temporary Housing O Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over"5-yrs old) 0 Other—Please Specify I If the required fee and attachments are not included with tins application, it will be returned to you as incomplete. Post the orange cardat 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- I Mark Krautmann of Mark&Jolly LLC 503-585-9835 Applicant's Name—Please Print Legibly Applicant's"Phone`Number DEQ Lie.# (if applicable) 1 4194 71st AVE SE Salem OR 97317 - " I l Applicant's Mailing Address 5/10/2019 I 7R4,74/L__ Xra 447i..4.4..,/ i Signature Date: CCB# (if applicable) t Applicant is the VOwner 0 Authorized Representative ❑Authorization to Apply form Attached i i 1 t f.