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a3 naa 5 7 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> — -: Wastewater Treatment System City of <br /> MI <br /> Date Received ® I I C �/ <br /> MARION COUNTY PUBLIC WORKS Received by <br /> -"T) <br /> BUILDING INSPECTION DIVISION Zoning by [4AR 15 2023 <br /> 5155 Silverton Rd NE Fee — 'J <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> www.co.marion.or.us/PWBuildinnInspection Activity# BUILDING INSPECTION <br /> - - - .. . A Prpp.eity Owner Information <br /> ' e5 63 l V /-44a5 t'i L e. it); 5L /e. Va--9/f�rJ -I'j -)-73 -3'q <br /> N <br /> GJQ V� "1at Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Le al Pro a Descrl tton <br /> I gal Description Tax Lot Acreage or Lot Size <br /> ubdivision Name IN, Alizck <br /> L(6 4e.kds &mod . io S lei Ca 573e)5- <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> :C Existmg Facility/Proposed Facthtp)Water Infoim.ation ; ,' <br /> Existing Facility: Proposed Facility: Water Supply: . <br /> Single Family Residence a Single Fancily Residence ['PublicL� Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring, Shared_yp <br /> T fA h <br /> El Site Evaluation ❑ Renewal Permit uthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement gi. Replacing a Dwelling <br /> El Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other' ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> W j -A Sr) -R) ❑ 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 Environmentalo Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Ac-FFx <br /> Applicants )) vi <br /> Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 63 Li 60 1-C44Js .EPIc taPie PE Sc,Lt ,, ©2 q '730s <br /> Applicant's Mailing Address <br /> La t 1-f,r7 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />