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„, _____ _,_ _ sz.:72koa. ..,4 4 q-- pail- <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ;A7 Wastewater Treatment System City of <br /> MI Date Received REC <br /> EIVE <br /> MARION COUNTY PUBLIC WORKS Received by D <br /> BUILDING INSPECTION DIVISION Zoning by <br /> o�� <br /> 5155 Silverton Rd NE Fee 'JUN 2 <br /> Salem OR 97305 <br /> 503 588-5147 Fax(503)588-7948 Receipt# <br /> ( ) Activi # MARION COUNTYwww.co.marion.or.us/PWJBuildinglnspection ' BUILDING INSPECTION <br /> K+ 5e,_l4xtnzz` A.Property Owner Information <br /> ee,R.i L klucii.te LLc 1. ) r.. ,x 90 ac, g,. •l,s r 0kz i'Kos 364/-41t'y1/ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description �l t <br /> Cf6...ts eraeyrztet, 3-1L <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 7C?&44 / A 1 t s k. Ce.t-re, 14.1 feefiz-S QvZ_. 9-73Os-`' <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> f <br /> C.Existing Facility/;Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ElSingle Family Residence 0 Single Family Residence ['Public <br /> �7 Name <br /> Number of Bedrooms Number of Bedrooms I) Private kit Ail <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Ea Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> al Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other ❑ 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 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 /> Oc 4..t f?,-c,.K.L LL S c�3 . 711—*1/&( 3 g46E-` <br /> Appliics Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> po C�,c r A.€-7 r~lt .-. t CqZ. '---738.I <br /> Applicant's Maili ddress <br /> Z-(- (3- Z( 16%"3 <br /> ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner (g}Authorized Representative )Authorization to Apply form Attached <br />