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091 -W8')\"\c , <br /> Application for Onsite CityOnly: Date For Use P: <br /> -- Wastewater Treatment System city°f D C V f 1 <br /> Date Received1 U <br /> MARION COUNTY PUBLIC WORKS Received by 1 <br /> BUILDING INSPECTION DIVISION Zoning by AUG 18 202 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> .. 1.1 t 9 - ALA V tql 0Wngc0:: r igiSO 1 i .., ... . ._. _ . _ , <br /> Q-Phc,1 ,�,GGtek' P )gz®..1 A5 "-S s14.� or. 9�06 Scn3-3�2-6153 <br /> Name 1 ity Mailing Address C ,State,and Zip (Area Code)Phone# <br /> '�� <br /> e a t .7 B Le alP£o_pe:r c. GIIpt1U11 .<....... .... .»...... .. .�._._,.,. ..<..._, <br /> 5 2 T9_5 /Z6�' `IEv3 - � m eY2 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> fZ,`v-r vi rw far k Tarr'4ces .i__- I/ <br /> Subdivision Name Lot Block <br /> 117- a wo,2 ,iY`. 6-des or- G'/ 773Y6 <br /> Property Andress City State Zip Code <br /> Directions to Property: ?,2, , S}-712c, e lfe.S , i2. .�i7�'Qn / 4 'c St- A, 0nv/ <br /> 7' . E? sang fa-d.*:f Px. posed Facxlr /Water Inf.D atlDD:- 7 ay : Mra <br /> Existing Facility: Proposed Facility: Water Supply: <br /> gSingle Family Residence EL Single Family Residence ‘. l'ublic C'7 of GAL).$' <br /> 3 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> g t ' .. ..a yp8 O4 2.cpplIG4t1- .. . a ...... . ii �"i: .� <br /> 771 <br /> ❑ Site Evaluation El Renewal Permit ❑A orization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement Replacing a Dwelling t <br /> g Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooli'is <br /> El Major g Minor ❑ Existing System Evaluation El Personal Hardship <br /> El Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> _' � ❑ Other-Please Specify <br /> ��J � T40k, ��Ot, o <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 /> 9.:S©•i rv!�s ,mac, c�3-s? - Ll4 3�'�2 - <br /> App cant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> )2 7 80,- 57 /Lidlci , o r_ 97-3 6 m <br /> Applicant's Mailing Address <br /> 00$10/ 2.,a 2- I ` <br /> Signature Date: / CCB# (if applicable) <br /> Applicant is the❑ Owner 'Authorized Representative El Authorization to Apply form Attached <br />