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4,4*.\„( <br /> J <br /> Application for Onsite For City Use Only: Date Stamp: <br /> City of <br /> Wastewater Treatment System <br /> i- ^^° 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)588-514'7 Fax(503)588-7948 Receipt# <br /> • <br /> wwvv.co.marion.or.us/PW/Buildin Ins ection Activity# <br /> _ _.::. - ...A.Property Owner Information --- - — - — -- <br /> ( 0t#1-AJ 7 i'S4 -- (71 ee.642 LA) a44e5( pg. ?73e{CP llzs=a � <br /> i3-eri <br /> Name Mailing Address City, State,and Zip _(Area Code)Phone# <br /> '= B.Legal Property Description _ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 17.1 (veil 6A--45 o E q 9.3 y({) <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing .ty Facih /PiuP o ed Fa /Water Information" <br /> Existing Facility: Proposed Facility: Waterc ��� <br /> Single Family Residence Single Family Residence ublic f 1 <br /> 1J Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared - - <br /> :__ D.Typeof PP ca.§n _.._... ...._. ..._ _.. ...._:. <br /> - � A lice <br /> ,Site Evaluation ❑ Renewal Permit 1�� j •rization Notice for: <br /> ,construction Permit L Permit Reinstatement . P: Replacing a Dwelling <br /> Repair Permit (1_Permit Transfer II The Addition of One or More Bedrooms <br /> Vlajor ❑ Minor ( Existing System Evaluation ❑ Personal Hardship <br /> ❑ 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 /> 1;'' kti BO £/ $ . 2( )' el6e <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 124 Oec LA C,q-Fe s/ ole. 973C((P <br /> Applicant's Mailing Address <br /> .16,,,A....:,,, 4,,,...›,(------ . <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTICIS-01 ONSITE APPL SEPT 2018DOCX Rev 1/15,3/18 <br />