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01/09/2019 21:27 5038297676 AMERICAN ON SITE PAGE 01/15 <br /> .—rwe.ca i t— /To <br /> • <br /> • <br /> Date Stamp: <br /> Application for Onsite City o Use onl, 19_dCC D a D <br /> _ :_. Wastewater Treatment i5� f (C IE II V LE <br /> —=��Y:�� Date Received _ _ : !y� <br /> mie, Received by } <br /> System t <br /> Zoning <br /> JANo� <br /> Marion County Public Works Fee ?0�9 <br /> Phone: (503)588-.5147 Building Inspection Division Receipt MARION C� � <br /> Fax; (503)588-7945 555 NE Court St.,Ste.2260 b il.DING I¢� �s � �� <br /> www.co.marion.or.us PO Box 14500 <br /> Salem.OR 97309-5036 Activity# <br /> A.Property Owner Information <br /> Alittigii !" _ tei r i.., d, C ' ie, <br /> Name Mailing Address fly,State,and Zip (Area Code)Phone Number <br /> B.Legal Property Description <br /> CZ I'd • • tcoon <br /> 1$' <br /> COhA- <br /> legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name ' t Lot Block . <br /> Property Address: 0285v1.1 ' S' U1k'Z - �,4�-flock act <br /> Address City State Zip Code <br /> Directions to Property: <br /> — _ 1 t. • _a i.- h !. a -• y. *. _11 i . • <br /> C.Existing Facility/Proposed Facility/Water Information • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> .Single Family Residence [I Single Family Residence IR Public ,u lelf <br /> Name <br /> Number of Bedrooms • Number of Bedrooms 0 Private <br /> iNf Other 4 " - U- 0 Other el e'�P�o loft C,S Well.Spring,Shared <br /> MAK-1106 ec,G F2oDucTS — MikCNIN Y <br /> D.Type of Application ETA FLAVEE' 6P8-19-K-0G EDU IPIMENT( <br /> ■ ite EvaluationRenewal <br /> � 0 Permit ❑ Authorization Notice for. M�I N�V TO 6R EAK <br /> Construction Permit <br /> n' 0 Permit Reinstatement ❑ Replacing a Dwelling e&c,S Pkaa---SS K-A6E <br /> 1'1 epair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms r + �64C <br /> r Major 0 Minor Q Existing System Evaluation ❑ Personal Hardship S t I'P. tRE451/2t7DM <br /> J Iteration Permit ❑ Temporary Housing t4i 3D W its H <br /> r 0 Record Review 0 Connecting to ail Existing System Never in Use(over 5 yrs old) <br /> 1 Major 0 Minor <br /> 0 Other ---...... 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 /> OLmerc�v� Oh 3,,,,„1:1,- 5a3- Rzeq-7l,ob 3T514( <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3t8'/ S MARI 0-13 g03f <br /> Applicant' Mail' .. •ddress " " <br /> A.'::_._, , l.,11.1 / -'11 <br /> Signature d Date #(ifapplieable) <br /> Applicant is the ❑Owner ,®Authorized Representative [ Authorization to Apply form Attached <br /> CcFOaMSSIPruasar 1/2009Application.doe Page 1 of 2 <br /> • <br /> L <br />