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, / 71 ' 6,()XfZe.) co 0 <br /> Application for Onsite F;ate Stamp:in <br /> u L <br /> •,� �„4,,,a pp For City Use Only: B"'�, <br /> %%,� 3 Wastewater Treatment System City of g <br /> M Date Received `m 0 <br /> MARION COUNTY PUBLIC WORKS Received by Z <br /> c, nil <br /> BUILDING INSPECTION DIVISION Zoning by 0 0 ` ' <br /> 5155 Silverton Rd NE "1 C rat <br /> • Fee ITI <br /> . Salem OR 97305 Receipt# 0 Z tinece <br /> (503)588-5147 Fax(503)588-7948 P H <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> wcl <br /> A Property Owner Information i... .. . 5U .. _......_. ,_. <br /> �tCi 614 \ LD( o 1 ;1-(esi e.or-/Ve. Sets, 0 S <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description Cjr 1 r7 . _.... _._. ._ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> L-A &Sk. . 6--�RC2 5 1 <br /> Subdivision Name •- Lot Block <br /> (0s0 5 LcIA-(t I Q • 1/E . u ktA,1 O /7 3 o f <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 /> XSingle Family Residence ❑ Single Family Residence ❑Public <br /> L Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ 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 /> ❑ 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 /> Departmentof Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 4�--(i ' ' 'c. -.1,4,.L- <br /> Applicant's <br /> Applicant's Name—Please Print egibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address . <br /> , <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />