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,;, „ ,. Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> 1111111 <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A Property Owner Information <br /> YN \a-Ok SecurAmN 1453 3o rda.. o2se &,104.y. o? 973d? , <br /> .. . ... g „ B Legal Property Des nption p ( ) <br /> Name Mailin Address Ci State and i Area Cod Phone#e <br /> Legal Description Tax Lot Acreage or Lot Size <br /> o-e Drers a44 <br /> Subdivision Name Lot Block <br /> 4'5—h Nyvkx,a, ociL <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> F _ C Ex sting Facility/'-ProposedFacthty/Water Information. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence Single Fa ily Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms [Private <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> t _ D,_:Type o f Application .:.. <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor El 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 this application. <br /> W& Si <br /> t 45-F3-3 -5-71 3g�3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone umber DE applic Lic.# (if pp lic ble) <br /> o ( c0 q 3-377- <br /> Ap Haunt's Ma' 'ng Ad s <br /> cps ssco <br /> Si Date: CCB# (if applicable) <br /> Applicant is the❑ Owner Authorized Representative [Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />