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23_0OL1 1bi2 ►our la <br /> Application for Onsite For City Use Only: Date Stamp: <br /> _�--- Wastewater Treatment System City of <br /> Date Received D [E C E 1 7 <br /> Illi MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by ,. <br /> 5155 Silverton Rd NE MN 25 2g21 <br /> Fee <br /> Salem OR 97305 . <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARIO\I COUNTY <br /> wvvw.co.marion.or.us/PW/Buildinensnection Activity# <br /> w BUILDING INSPECTION <br /> A.Property Owner Information <br /> lW* 2261e5 IUvk ' �s, r1,�2 6/Z35 5b - ?02-/ ;7 <br /> Nam MailingAddress Ci ,State,and Zip (Area Code)Phone# <br /> B.Le al Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block . <br /> 2)01.kg Ai, kV al <br /> Property Address C' State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: • <br /> Single F�il thO <br /> Family Residence Single Family Residence OPublic . <br /> bb r►t/► wAn-; 5 Name <br /> Number of Bedrooms Number of Bedrooms V Privat <br /> ❑ Other ❑ Other We , Spring, Shared <br /> D.Type of Applica;on <br /> ❑ Site Evaluation ❑ Renewal Permit P i Authorization Notice or: <br /> ❑ 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 /> DI 41 s P7kPTPrah mew JX 3317 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# if applicable) <br /> 2 6 ` 40. Ariv& 1 uu��/, , 01 q -7MM�2 <br /> Applicant' ' in d ss <br /> r1L -11 12- Z3 . <br /> Signature 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 />