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• <br /> 555_n- bbbtQ.t.D <br /> doik,,,,,k,„„, Application for Onsite . For City Use Only: Date Stamp: <br /> ��--: Wastewater Treatment System City of <br /> Date Received y'� 1� J <br /> i- IVE <br /> MARION COUNTY PUBLIC WORKS - Received by !�l - <br /> BUILDING0 <br /> 515INSPEton Rd IVISION . Zoning by ! JAN 5 ?0�9 <br /> Fee <br /> Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948Receipt# = F <br /> COUNTY <br /> ;LDING INSPECTION <br /> www.co.marion.or.us/PWBuildingInspection cvy <br /> ! .. : ; ----= - - --__—_ - A.Property Owner Information <br /> V t V 4 S e-- Nt fcvskty Po '5 S(c)7 �c le c". O - 7)c� i 5-03-315/-1 y `I CS <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 /> vs5sq sit 54- KIE c% 0Q -731-7 <br /> Property Address City State Zip Code • <br /> - <br /> Directions to Property: <br /> • <br /> _ - - _ - - <br /> C .Exist.ngFacility/Proposed Facility/Water Information ..... ...... <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence ''P" Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ,E] Private k)el <br /> ❑ Other • 0 Other Well,Spring;Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> •j 'Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling • . <br /> O Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 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 /> Departmeg of E�fps ii ental Qualityhpermissionpeto enter onto the above described property for the sole purpose of this application. <br /> -PV\AX---Z <br /> iAck' e 4.1- re 14 L.. 5-0 3-4Del-z2g2- 3 gR /i <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> To ( 5C,07 t.1r.ew1. 6 r& 9 7-7-,c1 <br /> Appli ill's Mailin_Address <br /> Signa e Date: CCB# (if applicable) <br /> • <br /> r Applicant is the❑ Owner Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC1S-01 ONSITE APPL SEPT 2018.D CX Rev 1/15,3/18 <br />