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Application for Onsite For City Use Only: Date Stamp: <br /> - 7v Wastewater Treatment System City of RECENE <br /> — <br /> Date Received, - \ <br /> MARION COUNTY PUBLIC WORKS - Received by <br /> BUILDING INSPECTION DIVISION Zoning by _ MAY 12 ZOZZ �J <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MAR7ON COUM <br /> (503)588-5147 Fax(503)588-7948 Receipt# ��BL�B� INSPECTI®� <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> :....—A Property Owner Information - -� : <br /> P/4 tf / A ) ' of /65-1a-/ A f 5� fr? a. 92Yg/ - 3 -m3/2-z <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B•Legal Propert )escnption <br /> Legal Description Tax Lot Acreage or Lot Size <br /> V t` 06/tv32�b 9 9D/ - / �, 19 <br /> Subdivision Name Lot i Block <br /> // if? #3{/. fa �.e,k -� <br /> 9)y6c7/. . <br /> Property Address City State lip Code <br /> Directions to Property: OP e Cry n RV D - c i- <br /> - E C- Existing Facility/Proposed Facility/Water Information • i <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence j21 Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms X Private W <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D T e of A lication <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> LJ 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 ❑ 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 /> PJ i aek50 J ca 3 / 2 29 AV <br /> Applicant's Name—Please Prmt Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> h5S--- 0.0216 A 574, c/I i./,e k / . <br /> Applicant' in ddress <br /> `" 'S / 2 <br /> 0 .UG t <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the/Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />