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M -- DOC q\--1 -Au.AL Application for Onsite Date ..440,--t„,„4,;.. pp For City Use Only: Stamp: Wastewater Treatment System City of .. Date Received MARION COUNTY PUBLIC WORKS Received by D {E C IE li v IE "1 BUILDING INSPECTION DIVISION Zoning by 5155 Silverton Rd NE Salem OR 97305 Fee U 6 2019 .J (503)588-5147 Fax(503)588-7948 Receipt# CINTY• MAR{©tV www.co.marion.onus/PWBuildingInspection Activity# BI 111 DING�NSPE ON A Property Owner Information )keel v Cl(S `4' ee_c.e l,y÷ G t --e B y17'( 34cp t-fe e s ow,O R- 9 7 3,-c-.-- Name _ Mailing Address City,State,and Zip :... ._...(Area Code)Phone# -:.. - _ B.=- -- - - B Legal Property Dem iytion — Legal Description Tax Lot Acreage or Lot Size • Subdivision Name Lot • Block • X . t 3 G' .re f e s o n) Sc./0 o R%v e✓ \ie-F--c--e R_C o 0 Q7 7 .S-Z Property Address City State Zip Code Directions to Property: ( yam_ ,c;`,...,, o -r, G� 02,....a'1„- 0. rvt..cra-41. Ph-► ...�� Siz . i�rr,_tJf s .P h-ie-=� j// R o RI)Cu_i C Existing,Facility/Proppsed Facility/Water Information Existing Facility: Proposed Facility: Water Supply: A i n g 1 e Family Residence Single Family Residence ❑Public I Name Number/of`Bedrooms Number of Bedrooms M.Private ❑ Other • 0 Other (Well, ppringShared :D Type of Application ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling • ❑ Repair Permit ri Permit Transfer ❑ The Addition of One or More Bedrooms ❑ Major ❑ Minor ❑ Existing System Evaluation Personal Hardship ❑ Alteration Permit (] Record Review 0 Temporary Housing ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use (over 5-yrs old) ❑ Other-Please Specify If the required fee and attachments are not included with this application, it will be returned to you as incomplete. Post the orange card at the entrance to the property. Flag the test holes. By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) e--) -71-q i'T-P fife r s o►v &'1 9 7 3 2. A licant's Mailing Address C $ °t/iq Signature Date: CCB# (if applicable) Applicant is the[ j4 ner ❑Authorized Representative ❑Authorization to Apply form Attached G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18