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• <br /> Application for Onsite <br /> �,� ;,�� Pp For City Use Only: ® �� ,(---���� <br /> -- Wastewater Treatment System city of 'lu�� <br /> rill <br /> ""'"""', Date Received <br /> MARION COUNTY PUBLIC WORKS Received by FEB 2 7 2017 <br /> BUILDING INSPECTION DIVISION Zoning by 7 <br /> 5155 Silverton Rd NE MARION' COUNTY <br /> Salem OR 97305 Fee JILDING INSPECTION <br /> • (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.onus/PW/BuildingInspection Activity# r 7raz,P00/c7 . Mr <br /> A Pro e Owner Information- 1 <br /> n'te4 J,� Cr. 46t0�Q e''ue ' A'OOSrix $a •S71-y7`obu, (.)A ?J'3'qI3 512,5- 6--:5% 59044 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Prope Descriptton _ <br /> L/6' '�, I. /eaw ,?.,d a`�. ReS a`. t>) p !' $cD c5 / ig, a a2. <br /> egal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> /6 S i a, FR4 a;,15.� flet -76.-7 ; a/4.r. ` ? 3 9'3 <br /> Property Address City State Zip Code tf <br /> Directions to Property: 3 A I Oa.si 6-f' /V te.y a c r, FN//1J//#09 s £* Q <br /> E F- 7 CExistm Facto iffoiiiiiiilialiii,WaterInformatton <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence ❑ Single Family Residence ❑Public <br /> li 4 r.b 41 Name <br /> t Number of Bedrooms Number of Bedrooms [-Private ,5'1r R ;01,1 <br /> ❑ Other ❑ Other Well, Spring,Shared <br /> _ ; D T e ofA hcatton <br /> ❑ Site Evaluation ❑ Renewal Permit - DAuthorization Notice for: <br /> ❑ Construction Permit El 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 El 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 sole purpose of this application. <br /> /'h e L. V:0 , 8©€.rQr',p hr-,mc.0 j r,3.•,J^,3'/..J'3 0 9 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P. e . r30 Y g? 5 7'...y Tos0 67 A ft-- 9 ', 3 8 3 <br /> Applicant's Mailing Address <br /> r <br /> i; viii - �.�i�_--- cX " a — ) 12 <br /> Signature / Date: CCB# (if applicable) <br /> Applicant is the rig Owner El Authorized Representative 0 Authorization to Apply form Attached <br />