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Vi.(41.A <br /> r� ���"J <br /> Application for Onsite G-�' "' n <br /> PP For City Use Only: 0.7. p: v r/ <br /> "\��� City of <br /> .Wastewater Treatment System Z M <br /> 111 Date Received f�(7 <br /> MARION COUNTY PUBLIC.WORKS <br /> Received by m O N <br /> BUILDING INSPECTION DIVISION Zoning by 0 Z M <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 0(503)588-5147 Fax(503)588-7948 Receipt# Z �� JJ <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information_ <br /> Sufi- Lc.BLS 14; 17 g.,23 S- Jtiesj-!e I-4,c 0(1e,o N e.f.(2 <br /> oX- 3 r,1 %s.9 <br /> MailingAddress City, State and Zip97,0 q! (Area Code)Phone# <br /> Name -.... --- _.. _... ._ ... r.- <br /> B.Legal Property Description <br /> RAM diAj 144 -- )1' <br /> Tax Lot Acreage or Lot ize <br /> Legal Description Q',id,5' Lu-��//f�' � ��� j e� © 3�� g <br /> Q/L�� Pa 0wJ�� O�" f Block <br /> Subdivision Name De (?rn'i Lot <br /> /SD ( A,- r J 4u e 0", .i e,a- 9 7 e vc <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 0 Single Family Residence ublic <br /> J I`11" Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> 0 Other - 6, - ❑ Other - Well,Spring, Shared <br /> (1.Uvi . D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit \' ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0., ❑ 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> I g 3 . .I bc5 -r LL'd e-- 6C Ord Gt orz, 9oyS .--- <br /> Appli .i is Mailing ddress <br /> tilpide <br /> Date: CCB# (if applicable) <br /> Applicant is theyOwner 0 Authorized Representative 0 Authorization to Apply form Attached <br />