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7:3 <br /> /9perazw <br /> Application for Onsite For City Use Only: <br /> Date pm <br /> Wastewater Treatment System City of . <br /> Date Received ia t.`v <br /> MARION COUNTY PUBLIC WORKS Received by `r <br /> BUILDING INSPECTION DIVISION Zoning by 0 <br /> 5155 Silverton Rd NE Fee i <br /> Salem OR 97305Receipt# <br /> Fa <br /> (503)588-5147 Fax(503)588-7948 L G <br /> www.co.marion.or.us/PW/BuildingInsnection Activity# ®' e <br /> A Property Owner information <br /> �� _ mss <br /> Matthew Stewart 276. eu ler Road S —Salem Oregon 97302 _(503)_931 5768 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Property Description' <br /> 2 acres <br /> Legal Description Tax Lot <br /> Acreage or Lot Size <br /> Subdivision Name Lot <br /> Block <br /> 2767 Keubler Road S Salem OR_ 97302 <br /> Property Address City State Zip Code <br /> Directions to Property:_I-5 to Keubler Road Interchange,_right_on Keubler to the property <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> XSingle Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> X Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ 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 /> Norman Bickel] _(503)_510_1742 None <br /> Applicant's Name–Please Print Legibly <br /> Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address 2232 42nd Ave SE#771 Salem,Oregon 97317 <br /> Signature Date: CCB# (if applicable) <br />