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o Date Stamp: <br /> Application for onsite ®r City���®��: <br /> n City of ( M <br /> Wastewater Treat 1111��11t System <br /> Date Received_ `J V I'—� w� <br /> EllMARION COUNTY IFN�o-.IL1iC WORKS Received by <br /> IeUIIILI DING II'NSIFECTIION IIDIVIlSI1ON Zoning by -1 <br /> 5155 SSnlver'ton NE Fee MAY 2g 2019 <br /> Salem47Olt9(5 3 Receipt# MARION COUNTY <br /> Quo 5rion.o9 Yam rWQ�®�)586-994c Aetnvnty# �,UILDINGINSPECTION <br /> twww.co_marion.or.us/PW/Suildinhispectio n <br /> A:Property Owner Information <br /> {�`. ,\ SI A <br /> N <br /> Mailing Address City,State,and Zip (Area Code)Phone# <br /> Name B:Legal Property Description <br /> Ib L)3t S Hap 0 6 <br /> Legal Description <br /> Tax Lot Acreage or Lot Size <br /> ------------- <br /> Subdivision Name sl , , <br /> Lots Block <br /> a__135- -- <br /> r monvolt kwakli6,-,,- -t.4:-._, c IilLIState <br /> Zip CodeProperty Address City <br /> Direction to Property: <br /> C.EustirigFacility;/`ProposedrFacility//'Water Information <br /> Proposed]Facility: Water Sunplully: <br /> lE�tuDng]Faieilutg�: ®Public <br /> 0 Single Family Residence l+ Single F?tinily ResidencePublic <br /> Number of'�:edrooms [Private <br /> Number of Bedrooms <br /> © Other © ®they Well,Spring,Shared , <br /> t, 'jipe'ofApplibdtiori . <br /> 0 Renewal Permit ❑Anntlloorization Notre for: <br /> Site Evaluationa lads a <br /> Construction Permit 0 Permit Reinstatement 0 ep acingAddition Dwellingof One or More edYooms <br /> ❑ Repair Permit 0 Permit Transfer ❑ personal Hardship <br /> © Major 0 Minor 0 Existing System Evaluation 0 P Temporally Housng <br /> ❑ Alteration Permit ❑ ecord"'eview <br /> 0 Major ❑ Minor © ®they <br /> ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 propel ty. 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 unto the above described property for the sole purpose of this application. <br /> x�(� 1 'l► 1 - _ i____ — �p- <br /> LJ�``�I- ;,r?j; it # (If at�'��{��h.C;! <br /> ;'t„ licani'5 Phone INu'nbe <br /> Ai�:31i^8.i"1� S Name-Please Pi-int'-,e'?ibd a <br /> Applicant's Ma'ling Address — — <br /> 'T- — -- OCEAl, (if applicable) <br /> Signature <br /> tate. <br /> Authorized Representative <br /> 0 Authorization to Apply form Attached <br /> Applicant is the 0 Owner <br />