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Application for Onsite <br /> rat; t/use only: 1 C tl <br /> Wastewater Treatment System atyern <br /> Dateto Received j' <br /> MARION COUNTY PUBLIC WORKS Received by �J L AUG 2 3 2017 J/ <br /> BUILDING INSPECTION DIVISION Zoning by MARION COUNTY <br /> 51 Sal55 em OR 973lverton d NE Fee BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinelnspection Activity# <br /> A.Property Owner Information ,,// / // <br /> ,O Ave el Sflr4At✓ /e3ZO7-o4eiMI#i lidt eloetno,3z,l'S -W/ /43 <br /> Name' / Mailing Address City,State,and Zip (Area Code)Phone# <br /> ! / w ` 36 E B.Legal Property on 12 4/ <br /> Legal Description 1K. L� Tax Lot Acreage or Lot Size <br /> Subdivision Name / Lot I Block <br /> /f3Zo A hei 1- if Z4 it l-!Y 02 9703 2— <br /> Property Address ` //-- City // ` State Zip Code <br /> Directions to Property: 4.-4 S/�-Gr 4�t /l _Lc, ,glef/ <br /> eci <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: !n/aJ/ <br /> It Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> O Other __ 0 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 /> �t] 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 enhance 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Zarrfq ClanJer 5b3 -6'30.- 136 Z <br /> Applicant'$Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P,D r (30x s7/ si-y / 6`,1.,_ e 9702._Z <br /> Aix?.nt's Mailing Ad. s <br /> ir .4.4 ,I of, , S A - ?0 /7 <br /> Signature ���Daatt'''e: CCB it (if applicable) <br /> Applican is the 0 Owner gl Authorized Representative ,'Authorization to Apply form Attached <br />