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5-56-- 21-01 Ili ?'?- PK olT <br /> Application for Ons ite Forcity Use Only: Dale SUMp: <br /> .--- -'--'---;---, Wastewater Treatment System City of <br /> mail......s------, ,..., — D ECEIIVE ..'.• <br /> IMIni Date Received <br /> IVIAR1ON COUNTY PUBLIC WORKS <br /> Received by <br /> --1 <br /> BUMBING INSPECTION DIVISION Zoning by. _ _ th <br /> 5155 Silverton Rd NE NOV 1 7 2021 <br /> Fee <br /> Salem Olt 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt#_ _ MARI N COUNTY <br /> www.co.marion_or_us/PW/BuildingInspeetion Activity# SU I LDI N INSPECTION <br /> A. Owner Information <br /> _ Property <br /> % <br /> ifi7e,rt) , e., C a4 ._. . A 1 ,--;...7 ar."." <br /> 1 7 _ 6,. 4,0,,,, , , _ ur kiy% uk / LiV -)4.5d05 <br /> . <br /> Name _ failing Address City,State,and Zip <br /> • 41,3'y <br /> (Area Code)Phone# <br /> B.Legal Property DeseriPtiOn - - -- <br /> .. _ • __ ___ __ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> P ;-• y Address City Sta le Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> cgSingle Family Residence El Single Family Residence ElPublic <br /> Name <br /> Number If Bedrooms Number of Bedrooms D Private Y <br /> Cj Other 0 Other Well Sprint, Shared <br /> .__ <br /> I).Type of Application, . , <br /> , . . <br /> D Site Evaluation 0 Renewal.Permit (TjAuthorizatiou Notice for: <br /> .n Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit ri Permit Transfer El The Addition.of One or More Bedrooms <br /> 0 Major D Minor 0 Existing System Evaluation D Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporaty Housing <br /> D Major 0 Minor 0 Other _ U Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> If the rcquiredfee 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 /> Deparim at of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> ....7 , / <br /> . <br /> _ - <br /> Amalie ' Name-Please int Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> a9,1)s <br /> -.) ____ 1 ?..//CA-0 <br /> /6---) -1. t , <br /> J-t-,7 es' --,--) F-• <br /> LI( , i KD. if <br /> Applic, s S•faiIini Addre .- - --- <br /> t_....."--- ed.-/1-....../ (/-1 7-24 /F.2-74`.J <br /> __ ______ _ _ <br /> Si attire Date: CCI3 it (if applicable) <br /> Applicant is the 0 Ovrscr Authorized Representative rj Authorization to Apply form Attached <br /> GAFORMS‘SEP TIC'S-0 1 ONSrrE APPL SEPT 2018.' , Rev 1/15,3/18 <br /> _ _ <br />