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Nov 15 18,04:42p Danielson Contractors Inc 5037622459 p.1 <br /> - I EI.Db8g55 <br /> Application for Onsite For City tee Only: Dole Stamp: <br /> —= - Wastewater Treatment System City <br /> of � <br /> Date Received <br /> Received <br /> 1 aill _, . 1_ ..,._n \-D-\ <br /> MARION COUNTY PUBLIC WORKS by '-� NOV 2� 2018 � <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 `AIAR i O 1N COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BL ILDING INSPECTION <br /> www.co-marion.or.us/PW/Buildinainsaection Activity# <br /> A.Property Owner Information EXPIRE Q <br /> 1 <br /> Sonia Kellas/ Dave Danielson 5106 SE 99th ave Portland Or 97266 503-519-5135 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Lot 13 BIk 6 Hammond Addition 105E01CB08600 85x89.00 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Hammond Addition _ Lot 13 Block 6 <br /> Subdivision Name Lot Block <br /> 137 Patton Rd S Detroit Lake Or 97342 <br /> Property Address City State Zip Code <br /> Directions to Property: Patton Rd to Flag lo:Driveway East 100 ft <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> It Single Family Residence 0 Single Family Residence ❑Public <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application . <br /> Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> [a Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major IlkMinor ❑ Existing System Evaluation 0 Personal Hardship <br /> Alteration Perm ❑ Record Review ❑ Temporary Housing <br /> ❑ Major Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> i. • (over 5-yrs old) <br /> D 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 /> tN � 60S 6l 51.35 <br /> c� Legibly A Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Name Please Print pp <br /> -V e• E 99t ave rte d Ore. 97266 <br /> iiii • 's Ma 'ng <br /> ` ' .1 l''' )4- 'i. . <br /> 1 Date. CC:t <br /> gi-t6 <br /> t41 11e # (if applicable) <br /> Applicant is theOwncr 0 Authorized Representative ❑Authorization to Apply form Attached <br />