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ali-603,\\0 <br /> ..... <br /> -- — • ECEINI ' <br /> ii \ _ <br /> Application for Onsite •Fwatyummir <br /> , I <br /> 1, <br /> Wastewater Treatment System chYof RE VD <br /> 1 iiiiaai Date Recei ved <br /> Ii M MARION COUNTY PUBLIC WORKS F4''''''''''"Y <br /> if - MAR 1 8 2024 <br /> ii . BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Saverton Rd NE Fee <br /> Salem OR 97305 <br /> II (503)583-5147 Fax(503)588-7948 Receipt!, <br /> www.co.marion.or.e.s/PW/BuRdindosnection ActivitY <br /> A.Property Owner Information <br /> 1i LLL fae <br /> F:—Cam=---"'Mniling Address City.State,and Zip (Area Cot <br /> B.1..egal Pmperty Description <br /> Legal.Description Tax Lot Acreage or Lot Size <br /> 1 t <br /> Subdivision Name <br /> ( <br /> I I t..33 12404440e.k.A cie&6-- LOt Block <br /> INAS <br /> Property Addreiti Ci State Zip Co <br /> Directions to Property: <br /> O.Existing Facility/Proposed Facility/Water'Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> DSingle Family Residence g Single Family Residence CiPublie <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ,„/4 Private 1.116" <br /> O Other 0 Other Well,Spring,S <br /> ,D.-Type of Application <br /> a Site Evaluation 0 RenewalPennit 0Authorizadon Notice for; <br /> O Construction Permit 0 Permit Reinstatement iiii Replacing a Dwelhia . St Pors.o.) <br /> 0 Repair Permit 0 Permit Transfer El The Addition of One or MoreBedr <br /> gl Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> O Alteratiort Permit 0 Record Review 0 Temporary Houslag <br /> 0 Major 0 Mliior 0 Other 0 Connecting to:an Existing System I <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> 1 <br /> If the required fee and attachments are not included with this application,it will be returned to you as inomplete. <br /> Post the orange card at the entrance to theproperty. Flag the test holes. . <br /> , By my sigmture,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized <br /> Department of Environmental Quality,permission to enter onto the above described property for The sole purpose of th <br /> (SO& -Sgo-4-No%2 39 36i <br /> Applicant's Name—Pleasefrint Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 9. o. S.26_44,0( Aa-t_ 6 ie c-a <br /> Applicanes Mailing Address <br /> 3/4 /2-4 <br /> Date: CCB# (if applicable) <br /> t <br /> , - <br />