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55- ez,1- of 012\- ASH <br /> .� <br /> , ,,,u� . <br /> • Application n for Onsite <br /> For City Use Only: Date Stamp: <br /> .7-7 .I:i .,._ Wastewater Treatment System city of iii. ,,. Date Received ® E C E V <br /> MARION COUNTY PUBLIC WORKS Received by ..� <br /> BUILDING INSPECTION DIVISION Zoning by _1 <br /> 5155 Silverton Rd NE Fee r t 1 OC f ® 8 ' gg <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARI ON COUNTY <br /> KT . €itot ....: _ 5:_._le, Activity# <br /> f_ftzBUILDING INSPECTION <br /> A.Property Owner Information <br /> ..©kk- Z 9 Le-i-< 7[5'S I si s-t-- Kk�y.,.t-(9r 9,�0e73 sv3 — 39D—USrYCD <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> °15-6-5 FI/ ()rw ,,,,o04s Gr k p i �[ 9 7.3St� <br /> Property 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 /> OSingle Family Residence Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private /,t✓e�f' <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application/ <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement fEj. Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal EIardship <br /> 0 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> Applicant's Mailing Address <br /> c cis J o II '11 177063 <br /> Sig ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />