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• <br /> , - .01A°bCD al CA 7 <br /> . . <br /> , . <br /> Application for Onsite . For City Use Only; Date Stamp: <br /> —'—"--=---- --;--------C" . Wastewater Treatment System City of . <br /> 1111111Date Received <br /> MARION COUNTY PUBLIC WORKS <br /> Received by EDC'EC E2z1112V02011ED. <br /> au ' <br /> BUILDING INSPECTION DIVISION Zoning by <br /> ITIO <br /> 5155 Silverton Rd NE Fee NIL1ADRINIOG\1COUN <br /> 1KISPECY <br /> Salem 0R97305 • <br /> (503)588-5147 Fax(503)588-7948 Receipt# N <br /> • <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> , • . . • <br /> . . A.Prciperty OWner Information . . . ; <br /> RObtef ". rCir PD .6ox .5)(00 8-1_12,02_or) cX q-15,04 515,8(.04-2q70 <br /> Name - Mailing Address City,State,and Zip • (Area ado Phone# <br /> : . . B.LegalPro_perty Description. . • <br /> a3FjjAe0D1DM ' .•15 Acie.t <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> * • <br /> Subdivision Name Lot Block - <br /> /00Z-6 14eAlk-- ric be, . Lion5 ofk °I-7353 <br /> Property Address City J State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0Single Family Residence K Single Family Residence OPublic • <br /> , '-I -1 • Name <br /> Number of Bedrooms Number of Bedrooms ,0 Private hard Ide 1 I <br /> 0 Other ' 0 Other Well,Spring,Shared <br /> --7"11.tiiii a-.4pliiplipii-77--------I'--''-'7.---- ' .--'-----:'-----1 <br /> El Site Evaluation El Renewal Permit V,Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement ' . 'A Replacing a Dwelling - . <br /> 2. Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> El Major it Minor • 1=1 Existing System Evaluation El Personal Hardship <br /> 1=1 Alteration Permit _ LI Record Review 0 Temporary Housing <br /> El Major El Minor El Other I=1 Connecting to an Existing System Never in Use <br /> . (over 5-yrs old) <br /> El Other-Please Specify <br /> ' . <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 /> 40 LI c, , <br /> 1 -‹ s co 3 - -- .7 I - 0 0 0 kr 7 cl <br /> Applicant's Name-Please Print Leg* Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 2:530_, t 13.r.cc,Lie.,i(. • Rot , NLE ,, ./).<1 e vt;., Or., 9730 'S <br /> Applicant's Mailing Address <br /> Ot C-. 1.6 2_0 -LC) -Z. 1 S3 ' 1 • <br /> 1 <br /> Signature " Date: CCB# (if applicable) <br /> . • <br /> Applicant is the El Owner iuthorized Representative 111 Authorization to Apply form Attached <br /> G:\PORMS\SEPTIC\S-01 ONS11.E.APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />