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,�i „ Application for Onsite For City Use Only: ��Stamp: ���3
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<br /> --=�:�=� . Wastewater Treatment System City of H
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<br /> Date Received J Mg MARION COUNTY PUBLIC WORKS Received by
<br /> BUILDING INSPECTION DIVISION Zoning by SAY 19 2023
<br /> 5155 Silverton Rd NE Fee � � :s: Ff��`+1
<br /> Salem OR 97305 �I� . 1�� i , SPEC ON
<br /> • (503)588-5147 Fax(503)588-7948 ' Receipt#
<br /> www.co.marion.or.us/PWBuildinglnsnection Activity#
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<br /> `br ,e..e.. ?Ds,c ,e,1 ck 9Asc 2W410 f(t)r0 Cw 01312°l 559 LI 3s 1115
<br /> Name Mailing Address City,State,and Zip (Area Code)Phone#
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<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> C1\11 5 \v.e( \ S V \:M1L. 52 °fl325
<br /> Property Address" City ' State Zip Code
<br /> Directions to Property:
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<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> jSingle Family Residence ❑ Single Family Residence ['Public
<br /> _ Name 1
<br /> Numb&of Bedrooms Number of Bedrooms NI Private �J�,,.(. 4,
<br /> ❑ Other 0 Other Well,Spring,Shared
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<br /> O Site Evaluation ❑ Renewal Permit . DAuthorization Notice for:
<br /> ❑ Construction Permit lc Permit Reinstatement .ElReplacing a Dwelling
<br /> 154 Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms
<br /> (1 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship
<br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing
<br /> 0 Major ❑ Minor ❑ Other 0 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.
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<br /> Applicant's Name Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> Applicant's Mailing Address
<br /> #14/-zie___. Sp )-)2') °nqI`S
<br /> Si ature Date: I CCB# (if applicable)
<br /> Applicant is the❑Owner )0 Authorized Representative Authorization to Apply form Attached
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