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Application for Onsite Date Stam <br /> .� pp For City Use Only: P� <br /> p _�- Wastewater Treatment System City of DIE (� _�/ 7 <br /> E <br /> —, <br /> Date Received <br /> a MARION COUNTY PUBLIC WORKS Received by — u APR 2 9 20197.. <br /> BUILDING INSPECTION DIVISION Zoning by '7 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# , '��J (o P <br /> A.Property Owner Information <br /> Fett f i.4.fi5ti..--- C�{5l e-Je,(...(A-C4 sr Sc.1,2—., lovz 4'13i"7 /(—/I Z—cLs I(, <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 178027'3 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 6 y zz 6,)4.1,,, Gt-5. — S., O32 q! 1---7 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence Kii Single Family Residence ['Public <br /> '( Name <br /> Number of Bedrooms Number of Bedrooms [p Private 41.11 <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> RSite Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Q Major ❑ Minor ❑ 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 /> Oregon Sewer& Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton, OR 97381 <br /> Applicant's Mailing 'ddre.s <br /> —2al—j°7 201683 <br /> Si a e Date: CCB# (if applicable) <br /> Applicant is the❑Owner ®Authorized Representative ❑X Authorization to Apply form Attached <br />