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ta-bt)57k <br /> Application for Onsite <br /> •,i�}ill+:,,,,� YY For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> ---mui,..-2.--- <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by D I , —, <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee JULU27 <br /> Salem OR 97305 201 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buiidin�Inspection Activity# �/i i 11ON COUNTY2018 <br /> oulLOiNO INSPECTION <br /> A Property Owner Information. _ <br /> Andrew Downes 3904 Pringle Creek CT SE Salem, Oregon 97302 503-522-4512 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Legal Property Description <br /> 082W16C Dna". 2.26 Acres <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Green Hills East <br /> Subdivision Name Lot Block <br /> 5858 Sunrise Ranch Lane SE Salem OR 97317 <br /> Property Address City State Zip Code <br /> Directions to Property: Gath Road, Turn on Lipscomb, Turn on Sunrise Ranch Lane SE <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 Name <br /> Number of Bedrooms Number of Bedrooms ® Private Well <br /> ❑ Other 0 Other Well,Spring,Shared <br /> • D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ® Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> O Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> O Alteration Permit ❑ Record Review 0 Temporary Housing <br /> O Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 of this application. <br /> Andrew Downes 503-522-4512 35524 (Coffman Excavation) <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3904 Pringle Creek CT SE, Salem Oregon 97302 <br /> Applican's Maili g ddress <br /> A7/27/18, .�, 198902 (Coffman Excavation) <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the®Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />