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EB_,.; - Application for Onsite. For City Use Only: DateStsmp: <br /> — Wastewater Treatment System City Of <br /> - _ <br /> Date Received <br /> MARION COUNTY_ PUBLIC WORKS Received by <br /> Ili - BUMDL?G LNSPECTION DIVISION Zoning by <br /> 5155 Sfiverton Rd i°?F, Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt is - <br /> www.eo naarion.or us/P rW/Bunding nspection A r <br /> - :--. --- ,..Property Owiier.Infor on - -= - <br /> T mn 1,YJ &Lis4/d;sons. &d e e�Q 973a,2__ 5-03-S-m-9'7,2, <br /> Name M2,7m2 address - City,State,and Zip (Area Code)Phone <br /> : - - : : : :: ..�_ -��-,B::Lna1 property Description - "-:: '- --_ - !S- <br /> S L-323 C .. AD 1 n c� . . _ 1- -Wcr - <br /> Legal Description _ Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br />' IS62 Efkhs..n "SSEe q 7358 <br /> Property Address ' State Zip Code <br /> A ag ._ 1,- <br /> Directions w Property;�� o� � a�r�q u,•i c R - -. <br /> (l tn/tile• <br /> - - --- --- --_.. : . '_°-.-_C'£xis_ gFad y7I ProposedPacilityI Tahirinfoi natio _=-i;_' .- :- - - <br /> LSisstins Facility. Proposed Facility: Water Supply: <br /> QSingle Family Residence xi Single Family Residence ❑Public <br /> y Name - <br /> Number ofBedrooms Number of Bedrooms 27 Private Sp,-i"� <br /> • <br /> Q Other Q Other well,Sprmg,Shared <br /> -2 ---_ -'f---.::-. -:.-::::-.7::. . D.`Tvpe of Spplica€ton =-- ---__-..___ __ -s_--- _ - -'_ . <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> 6 Construction Permit Q Permit Reinstatement 0 Replacing a Dwe]Img <br /> Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 irliinor 0 Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review ❑ Temporary Housing <br /> 0 Major Q-Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> lithe reel-dikedfeeand attachments are not included with this application,it will be returned to you as fncompleie. <br /> Post the orange card atthe ecce m the property. Flan the test holes. - <br /> By my signature,i certify that the information I have fimnichea is correct;and hereby want Marion County,authorized agent of the <br /> &r <br /> Department of 'ironmental Quality permission to enter onto the above described property'for the sole purpose ofathis application <br /> L,...t�.lr1 �j/(fSaYI JR. 503- 673^7�5� 7 t!.03 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number. DEQ Lic._ (if applicable) - <br /> B7 7,8 C S 2- riwu ,1E Sauer- b ' '7301 <br /> Applicant's Mailing Address, <br /> irt;ZDV______:0- - il C U..).,34.M4413 1 I i 071.9.,bict , ..., ,, r 7.-• <br /> Si6atture 0 Date: CCB r. (if applicable) <br /> pplicant is the 0 Owner fl Authorized Representative it Authorization to Apply formAttarhed <br />