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^,,k,,�,,, Application for Onsite For City Use Only: Date Stamp:
<br /> ��-= Wastewater Treatment System `it'a
<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/PW/BnildingInspection Activity#
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<br /> Name Mailing Address City,State,and Zip (Area Code)Phone#
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<br /> Legal Description Tax Lot Acreage or Lot Size.
<br /> Subdivision Name Lot Block
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<br /> Property Address City State Zip Code
<br /> Directions to Property:
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<br /> Existing Facility: Proposed Facility: Water Supply: ,//
<br /> OSingle Family Residence Er Single Family Residence RiPublic i ek-r , F
<br /> 3 Name
<br /> Number of Bedrooms Number of Bedrooms ❑ Private
<br /> ❑ Other 0 Other Well,Spring,Shared
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<br /> ❑ Site Evaluation 0 Renewal Permit FAAnthorization Notice for:
<br /> ❑ Construction Permit ❑. Permit Reinstatement NZ Replacing a Dwelling
<br /> 2Repair Permit ElPermit Transfer ] The Addition of One or More Bedrooms
<br /> N. Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing
<br /> ❑ Major ❑ Minor 0 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 tl at.theinfonnation 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 /> rew C&Iver '?-/ ? /3 385-5
<br /> Applicant's Name—Pleasd Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)
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<br /> Appl' is ailing Address
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<br /> Signature Date CCB# (if applicable)
<br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached
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