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Application for Onsite . For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of . <br /> 1 MN <br /> Date Received D MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by • <br /> MAR 21 2022 l <br /> 5155 Silverton Rd NE Fee MARIONCOUNTYSalem OR 97305 •(503)588-5147 Fax(503)588-7948 Receipt BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> u .. . .:_ A.Picitterty Owner Information _. : . <br /> 72747%) <br /> me ! Mailing Address City State and Zip • (Area Code)Phone# <br /> B.:hegal Pro' ertyDestrri lion '. � " �{-� ` <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 17s t AL L� 1 0 -�Y/h v 3�Z.. g zln / <br /> Property Addrese City State Zip Code <br /> Directions to Property: <br /> C E fisting Faciltty/Proposed Facility/-Water Information . _...._... r_.-... _._ .......,. _ 71 <br /> ..._. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 0 Singlemily Residence ❑Public <br /> • `/�j Name <br /> Number of Bedrooms Number of Bedrooms Private L,0e-t,t <br /> .I Other � ❑ Other Well,Spring,Shared <br /> YP PPlication _ w Y „ f <br /> z <br /> DT eofA � i <br /> ■ ite Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> �i:'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 /> 5die.341- P,w►,..5 L (- - SD 3—�f 71 -30 O n RI 73-. 3$ 6 7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 2-' D I 13rnakkkt- Rd . I\J E, Sci_ Or, 9136 3 <br /> Applicant's Mailing Address <br /> A4 I, 14 2r72 z Z I Sag <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the❑Owner ,lb-Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018DOCX Rev 1/15,3/18 <br />