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,,,04,ty,y�, ApplicationFor City Use Only: �e Stamp:for Onsite r�a <br /> �� City of <br /> �}�unu1 <br /> . Wastewater Treatment System � � �Date Received, ® Ft <br /> MARION COUNTY PUBLIC WORKS <br /> Received by Z 0 n <br /> BUILDING INSPECTION DIVISION Zoning by Z' <br /> 5155 Silverton Rd NE Fee 2 <br /> (I) — <br /> Salem OR 97305 Receipt# ( 3 i O <br /> (503)588-5147 Fax(503)588-7948 p <br /> Activity# <br /> www.co.marion.or.us/PWBuBdingInspection 1 <br /> O <br /> A.Property Owner Information Z. <br /> 11'IW4 s � f'oy4.l I(I' 2`T1( 2exi-R2 Ctivi Pa&ili y � 'i13©lf (0r1 3 .-`f4I <br /> Name Mailing Address City, State,and Zip (Are Code)Phone# <br /> B Legal Properly Descnption - <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> !S18 Z N gi,vioot Hwy „le RirtAfiNv _ 9738,E <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> • <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> )-(]Single Family Residence 'RI Single Family Residence OPublic <br /> 3 Name <br /> Number of Bedrooms Numb5of Bedrooms ig Private WAYk,/Si Gree) <br /> O Other • ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ite Evaluation ❑ Renewal Permit ❑A nthorization Notice for: <br /> -1 Construction Permit ❑ Permit Reinstatement Replacing a Dwelling • <br /> Li Repair Permit 0 Permit Transfer 11 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor r ' Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit LJ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 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 /> iiQ� in41 IP.4 Sb3- sss- yoi <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 690(0 Ro1Wilk Se 5/62444 i OR, 9730h <br /> App ' 's Mailing Address <br /> ature Date: CCB# (if applicable) <br /> Applicant is the❑Owner [1 Authorized Representative ❑ Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />