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EXPIRED
<br /> ••*„.. ., Application for Onsite For City Use Only: vvv"'�'—00,0 6 6.7 Stamp:
<br /> City of
<br /> ��2-r-T= Wastewater Treatment System : {-, 7,� r r' 77\
<br /> iiii,_ Date Received l J i. 1
<br /> MARION COUNTY PUBLIC WORKS Received by di
<br /> BUILDING INSPECTION DIVISION Zoning by JAN 25 2021 - -I
<br /> 5155 Silverton Rd NE
<br /> Salem OR 97305 Fee MARION COUNTY
<br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION
<br /> www.co.marion.or.us/PW/Buildin2Insaection Activity#
<br /> ., " .. . � ,,1„ A.Property Owner Information . iNvonug4,� .. ,,, ;._ �?. ,3 . ,., II I
<br /> ljei, r r-Q, ) ) i7U�,�l / / Gov r s as� qctt-,e 5 0',. -75c-ig
<br /> Name Mailing Address CState,and Zip (Area Code)Phone#
<br /> ...,, B.Legal Property Description_ ss z
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> Subdivision Name Lot Block
<br /> 131 taJ r 5a, s-t- A- -L�S 9-� 3� {�
<br /> Property Address tate Zip Code
<br /> Directions to Property:
<br /> _,_ , _ ,,_z ,.,,,,,,, C.Existing Facility/Proposed Facility/Water Information
<br /> Existing Facility: Proposed Facility: Water Supply:
<br /> ['Single Family Residence ❑ Single Family Residence ❑Public
<br /> 3 Name
<br /> Number of Bedrooms Number of Bedrooms ❑ Private
<br /> ❑ Other 0 Other Well, Spring,Shared
<br /> D.Type of Application
<br /> ❑ Site Evaluation 0 Renewal Permit thorization Notice for:
<br /> ❑ Construction Permit 0 Permit Reinstatement Replacing a Dwelling
<br /> ❑ Repair Permit ❑ Permit Transfer The Addition of One or More Bedrooms
<br /> O Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing
<br /> O Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> 0 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 /> 1 Ja,r Y �L 1 e0 54, 5-0 3 -9 --.5 7r�
<br /> Applic is Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
<br /> '/ L° UL $ O- Ss`r C`', *.zs 0-c -73 U
<br /> Applicant's Mailing Address
<br /> • 44.e0 0 Ca 2. '2_
<br /> i I 5 ) '2, l
<br /> S rii Date: CCB# (if applicable)
<br /> Applicant is the El Owner 0 Authorized Representative ❑ Authorization to Apply form Attached
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