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<br /> Application for Onsite Date Stamp:
<br /> pp For City Use Only:
<br /> Wastewater Treatment System City of
<br /> Date Received
<br /> MARION COUNTY PUBLIC WORKS Received by
<br /> BUILDING INSPECTION DIVISION Zoning by
<br /> 5155 Silverton Rd NE Fee
<br /> Salem OR 97305
<br /> _. (503)588-5147 Fax(503)588-7948 Receipt#
<br /> www.co.marion.or.us/PW/Buildinglnspection Activity#
<br /> x 3z i'�
<br /> kc,v Oala ?-� 110010( N C4^eOR (1)11*( 3 )411i-x440
<br /> Name Mailing Address
<br /> City,
<br /> ity, State,and
<br /> Zip
<br /> (Area Code) #
<br /> raRis.WP.FFy-Tx �, : rAitLgg:Wi6 Dpton g " ;7:* , R7r'73:1377
<br /> t1awoo Ve
<br /> Legal Description Tax Lot Acreage or Lot Size
<br /> ttI0
<br /> Subdivision.J,T3aiie Lot Block
<br /> Property Address City State Zip Code
<br /> Directions to Property: -
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<br /> xisting Facility- Proposed Facility: Water Supply:
<br /> S _le F.,. y es n•- '' Single Family Residence ❑Public
<br /> s_ edam Name
<br /> N ober o : drooms Number of Bedrooms ® Private � 1(isc/Ue
<br /> ❑ other 0 Other Well, Spring,Shared
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<br /> ® Site Evaluation 0 Renewal Permit ❑Authorization Notice for:
<br /> • ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling
<br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms
<br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship
<br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing
<br /> El Major ❑ Minor- ❑ Other - - ❑ Connecting to an Existing System Never in Use
<br /> (over 5-yrs old)
<br /> El 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 /> At/161,:e Velenc)ite sqI-qO1- 9-g33 - -
<br /> Applicant s Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#.(if applicable)
<br /> CII 3 - i v RcQ ktycurgy) Of-CAMS-5—
<br /> Applic 's Mailing Address
<br /> � f- 19
<br /> Signature Date: CCB# (if applicable)
<br /> Applicant is the 0 Owner El Authorized Representative ®Authorization to Apply form Attached
<br />
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