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Zz <br /> ()D S 329 - ‘--1 <br /> , <br /> Application for OnsiteCity y: �m <br /> For Use Only: P� <br /> —��� \ City of <br /> Wastewater Treatment System J <br /> Date C <br /> .. <br /> MARION COUNTY PUBLIC WORKS Received Receivedby i"" M <br /> BUILDING INSPECTION DIVISION Zoning by e . <br /> 5155 Silverton Rd NE Fee ,cl� - M •) <br /> Salem OR 97305 z-- a <br /> 503)588-5147 Fax(503)588-7948 Receipt# C . ell <br /> d <br /> ( Activity# C =_� <br /> www.co.marion.or.us/PW/BuildingInspection - 'li!0 ^' <br /> me j <br /> A.Property Owner Information . M <br /> 53 S-° —ski c& i <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property, Description <br /> 'legal Description Taet Acreage or Lot Size <br /> fi 1 <br /> n ' eslEA,06 &_5 <br /> __.5 <br /> 0/Li <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 /> 0 Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms lid,Private <br /> ❑ Other ❑ Other Well,'.pring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit yr uthorization Notice for: <br /> ❑ Construction Permit ElPermit 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 /> CI 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 /> Ru ci i' A( /cC s��sD7 -s'c <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /S/ 01L/)i J. o1i}&1 l L/V S/LVe/g7m/ 0/5 , 9747c '1 <br /> Ap icant's Mailing Address <br /> Signature <br /> 1 cur <br /> S Date: CCB# (if applicable) <br /> Applicant is theP4Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />