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d -rbC11 7D <br /> a4, Application for Onsite For City Use Only: Date Stamp: <br /> -. � Wastewater Treatment System City of r—_, <br /> Date Received _Wit E'1 V' l'—� <br /> L <br /> MARION COUNTY PUBLIC WORKS Received by 6 <br /> BUILDING INSPECTION DIVISION Zoning by lA�\J ;8 7,U <br /> 5155 Silverton Rd NE <br /> Fee <br /> Salem OR 97305 a a ;�; t�/ <br /> (503)588-5147 Fax(503)588-7948 Receipt# N�1867 <br /> ��,�(_�,T, <br /> www.co.marion.or.us/PWBuildingInspection Activity# BUILDING 1 <br /> A.Property Owner Information brl t`�. gy,t c' nS- ri1C ort awl <br /> , rtana Jahnso, 2(03 NE Ri veistane /cop Alban�l OP 9-1-32 i 5o3 -(o eel-yZZ8 <br /> Name Mailing Address City,State, d Zip (Area Code)Phone# <br /> B..Legal Property Description <br /> - <br /> 093w12a 00800 7.18 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Mark IV Village 2 2 <br /> Subdivision Name Lot Block <br /> 3086 Continental DR SE Turner OR 97392 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ❑ Single Family Residence ❑Public <br /> 4 S Name <br /> Number of Bedrooms Number of Bedrooms 0-Private <br /> ❑ Other ❑ Other ell, pring,Shared <br /> D.Type of 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 /> ❑ 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. irpose of this application. <br /> Kyler Welch 503-932-8150 37465 <br /> r;a_. <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ'E #=(iapglicable) <br /> 6317 Nickalus Lp N Keizer, OR 97303 <br /> Applicant's Mailing Address <br /> '\ OR ® 11/15/2023 102802 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner X Authorized Representative ykAuthorization to Apply form Attached <br />