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I <br /> lie/1411f <br /> 1 is-d3q3- <br /> c <br /> rn <br /> 1,1Applscati n for Onsite For City Use Only: 2 teS • <br /> ' <br /> 0 . <br /> --��%�i Wastewater Treatment SystemCity of <br /> Z Y Ei <br /> iiii--------, <br /> Date Received z 0 Qo <br /> MARION COUNTY PUBLIC WORKS Received by m <br /> m <br /> BUILDING INSPECTION DIVISION Zoning by n 2 0 <br /> 5155 Silverton Rd NE --I ii =B <br /> Fee ® <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> _ A Property.Owner Information <br /> Pa ,Id.� Gevl le,r 9Y.- Prv..j tqf Lh NE I(Gelzer,. 0"1a 97303 91I-9-39-813'9-s <br /> Name Mailing Address City,State and Zip (Area Code)Phone# <br /> B Legal_property Description 3. <br /> t/2-/ores ./l (, 13 7 SF <br /> Legal Description Tax Lot Acreage or Lot Size <br /> CO 14 yov\ 12sd9e R-1-6.-1-es I cl <br /> Subdivisibn Name Lot Block <br /> (05 Mel 1 ea. C-f- 0e-root 02 973y2. <br /> Property Address City State Zip Code <br /> Directions to Property: I{ 22 fo 14ty-c+ sf tv (At(3arck <br /> C.Existing Facility/Proposed Facility/Water Infonnation <br /> Existing Facility: Proposed Facility: Water Supply: /r 11 <br /> ['Single Family Residence Single Family Residence BPublic Cd.-7cT 0 e)r"r <br /> 3 Name <br /> Number of Bedrooms , Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> =_ D.Type'of pplication . , <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 /> ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other ❑ 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 /> P CAll ay Ge►n3lPt 971-1.3 9- $825 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ?vs" Pr'e kcu+rsf LK )VE 1 ktr e✓, OR, 97303 <br /> App' is Mailing A ess <br /> S gna e Date: CCB# (if applicable) <br /> Applicant is the,5Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />