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• <br /> • c —cice5 -3-7q <br /> Application for OnsiteDate Stamp: <br /> atl „ '4urpnl pr For City Use Only: � ��� P <br /> —a =�,�� Wastewater Treatment System City of - D V[ <br /> �. Date Received, <br /> ' MARION COUNTY PUBLIC WORKS • Received by °V :CIS <br /> 2018 <br /> BUILDING INSPECTION DIVISION Zoning by �5155 Silverton Rd NE lVIl�l �C�liOUNTY <br /> Fee3l1'!LDIRIGIF'ECTIOP�R <br /> Salem OR 97305 - - <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> ------ _ .. : A.Properly Owner Information <br /> 3aiw► Sovvzs 'MI I4nbrtn Or. N Vt.iicr Olt.. ct131.), Sot-1q?r2M&,4 cell <br /> Name Mailing Address City, State,and Zip_...._.._.,.._.._....._...__.._ (Area Code)Phone# <br /> _ ' I B.Legal Property Description ._.._--' Atie,s <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot - Block <br /> • <br /> (OCAS Swett%a.c tr Ltd SE Salem 012 g1A41 <br /> Property Address �/` fit tate Zip Code • <br /> Directions to Property l�&f.o1rl c�.�'r �.'�' S h 1 p wiays• L&w. 'b L- gW e-g-i--a- ' Laura <br /> - C _Elting Facility/Proposed Facility/-Water Information.,... _ .... .. .... ... .. . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence g Single Family Residence ❑Public <br /> T Name <br /> Number of Bedrooms Number of Bedrooms g Private \NGI <br /> ❑ Other ❑ Other Well, Spring, Shared — <br /> D.Type of Application - ......_.. .. ...._. . <br /> ICSite Evaluation ElRenewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling • <br /> ❑ Repair Permit ❑ Permit Transfer ❑ 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 El 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 /> ,...)aew► 3o %es 503=19a-$59► 1014 88'4b0 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 183 Memlarin W.t,. Kuzer iDCZ• 913u3 <br /> Applicant's Mailing Address <br /> (**-- c4iv‘Qro`3t118 110 L93/ <br /> Signa Date: CCB# (if applicable) <br /> • <br /> Applicant is the VOwner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSt1'h APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />