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22 PR-InT <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ;,,�= Wastewater Treatment System City of <br /> Date Received <br /> :Mil . MARION COUNTY PUBLIC WORKS Received by <br /> ' BUILDING INSPECTION DIVISION Zoning by OCT 24 LU21 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 1NARION.COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.m a rio n.o r.us/P WBuild in gIns pectio n <br /> Activity# UILDING INSPECT ION <br /> A Property Owner Inmatio n for __. B <br /> _.._. <br /> 4tZ,( 464 {7 C 0 ZerX1 3q21? S.54Ekt 1 Oo2 1306 1/45'D3-g99- g <br /> Name Mailmg Address City,State,and Zip (Area Code)Phone# <br /> B Lega l Pro e Descrt tion <br /> 0S3 ► 1°1 3©® 6o ,o _ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Existm Fact /Pro osed Facili" /Water Information ' <br /> , Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence [X Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms [Private Ir/e/I <br /> ❑ Other 0 Other Well, Spring, Shared <br /> D e of A hcatton <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> E Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ 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 /> J.- ' <br /> / Ply : 05-°1 --?U C <br /> Applicant's Name 'lease Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) ' <br /> 9 -( 3 `1 Z S k,1 O CV O2 <br /> Applicant's Mailing Address <br /> d(7 1( j® Z2 <br /> Si re Date: CCB# (if applicable) <br /> Applicant is the❑ 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 />