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Application for Onsite For City Use Only: Date Stamp: <br /> ----%�;1�� Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> w.co.marion.or.us/PW/Buildinglnspection Activity# <br /> �� <br /> 3 A.Property Owner Information <br /> ' 0\se\T\ )\)-Q\A)n <br /> rTame Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Veoov\--\-a U&T. 4-L, <br /> ubdivision Name Lot Block <br /> SAS -UV CR cn D- <br /> Pro erty 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 /> 0 Single Family Residence liA Single Family Residence OPublic <br /> 7.3 Name <br /> Number of Bedrooms Number of Bedrooms n Private W L_, v <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> 'MI Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> O 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Applicant's Name—Please Print Legi i Applicant's Phone Number DEQ Lic.# (if applicable) <br /> VOln\i, SCA ` cjme o oD <br /> Apli,.u is Mailing Address <br /> ' t 1 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the❑Owner *Authorized Representative ❑Authorization to Apply form Attached <br />