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EXPIRED <br /> Application for Onsite Da <br /> ,,, k ,� pp For City Use Only: <br /> ;fimi �; 7 iWastewater Treatment System city of �� �r L�j <br /> Date Received, i� ) <br /> MARION COUNTY PUBLIC WORKS Received by \; , I T <br /> BUILDING INSPECTION DIVISION Zoning byt_ SEP5155 Silverton Rd NE . r•-taOGN tiNC N 3,,- <br /> Salem OR 97305 .y 11 %its "v 1— 1�' <br /> (503)588-5147 Fax(503)588-7948 Receipt# ? <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A Property Owner Information <br /> r an Arige)aktV,� S6b 3ilvflofl l $ q3a? 5Name YMailingAddress' City, State,and Zip (Area Code)Phone# <br /> tS', <br /> B.Legal Property Description r/ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> � vast [la)/e )?JlCel of q730 <br /> Pro a Address Cit State Zip Code <br /> P ►'tY YY <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ti Single Family Residence a Single Family Residence ❑Public <br /> LI Name <br /> Number of Bedrooms Number of Bedrooms ® Private well ,Sphrof <br /> ❑ Other ❑ Other Well,Spring, hared a <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit :i • uthorization Notice for: <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 /> givo, Roe '003 q3 4g1� <br /> Applicants Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P, 0 , i3 85 llver ion OF q7?) 7 / <br /> Ap 'cant's Mailing A ess <br /> ozo .;.M3 <br /> gna e Date: CCB#(if applicable) <br /> Applicant is the❑ Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />