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i <br /> /,-o o3 tp&oT <br /> -11-u1 <br /> Application for Onsite <br /> :: ,,,,., pp For City Use Onl � � //E mp: <br /> _ _—=-.� Wastewater Treatment System city of `,�JIJ <br /> Ni3MDate Received <br /> MARION COUNTY PUBLIC WORKS Received byAPR 12 2a�1 <br /> /9- BUILDING INSPECTION DIVISION Zoning by <br /> I 5155 Silverton Rd NE Fee MAi--tiON COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.onus/PWBuildin¢Insaection Activity# <br /> ::_. :. ..::::. :.,.... nformatioii _< <br /> N ...... .. ... _ . �:,.�. , t.::._ ..... .::.A.:Propetty::QwerL. ....... ....._._.._ .... __. .:....... . rS.iyg9 <br /> /ThMae/ 4i2a/( 3-1a90 Fay/rirar1, V. /-safes, 0e g734/1a 93a-757o <br /> a1 <br /> Name J Mailing AddressCity,State,and Zrp (Area Code)Phone# <br /> ". '.'93:', :, .: ........: <br /> :.: ...- :.:: ..:.<;.:: <br /> . . < :ie al° .ro e. :bescri tion<':;; 11�a. ;:=_ ; N;: >;;; :i; :: ;'''::;`-';`;; ; ::; "i:'::' <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 4 `390 /z,/,cy14ve &?-/es _ 73 S/, <br /> Property Address /� City at /y� State Zip Code <br /> Directions to Property: E i//�!�� /tL t v /�/Gt ,��/>, ke.,17 G x_e_ c__ <br /> .:.:.: ::::::.: ,. .ExtsUn Fac It < .ro o ed E gilt <br /> ,...... . P s aL.. ater.Inforrii i n: :':`::;= ; �' > < - : <_ :'':,'::::-:';; : :; <br /> . ..:_:.,...... ::....: : .:....: , :... .g xty L. .,p ty W.. at o - -. ... : .. . . ... <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence Single Family Residence ❑Public <br /> &a/V/3W (i/,fd7`i,, 3 Name <br /> Number of Bedrooms Number of Bedrooms id Private <br /> ❑ Other - ' 0 Other we ,Spring,Shared <br /> :. .... :......:....::. . .. ...: _._ :..... _.::;. .::T e;of A licati(iri°: ::: _..._.... :..: : ... 7 _..._. <br /> ❑ Site Evaluation ❑ Renewal Permit •A thorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement • N Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer E4_The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 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 /> Ziiv% X ehauLica/) 503- 991- 169r <br /> Applican 's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3'io as fazi46ad ,� ( 7. 973�/�Applicant's Mailingress <br /> � <__-,/ � c7/mol/ //26P'Sa5�/ <br /> rgnat��ure/" Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative <br /> pp p ❑Authorization to Apply form Attached <br /> G:\BUILDING INS ECTIOMFORMSISEPTIC1S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />