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23 -- O 7si 6 PRAA i <br /> ,,; 4j,,;„.. Application for Onsite For City Use Only: Date Stamp: <br /> ;l: Wastewater Treatment System City of " <br /> Date Received <br /> MI <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# <br /> (503)588-5147 Fax(503)588-7948• Activity# <br /> w ww.co.marion.or.us/PWBuildinglnspection <br /> . - — —_ A.Property Owner Information _ - --_- — <br /> re�nt i7 Miner I Sh3 Rr r Grove R()/i1t -illoo�Jh'i4 OR 9707/ SoJ-75z_-7Y7 <br /> Name/ - Mailing Address City,State,and Zip_ ___.(Area Code)Phone#_ ___ <br /> __ B. eal PraDesci on <br /> 04�►J7� o(3 6o, pri„ So, 7v 4C- <br /> Legal Description <br /> Tax Lot Acreage or Lot Size <br /> • <br /> • <br /> Subdivision Name • Lot • Block <br /> /g-G,3`r 4-r4A- Ire-dirt_ /1d AIF_ Vd aa1.ddc?,. DR- 9707 I <br /> Property Address City State Zip Code <br /> Directions to Property:_ _ - -_ --_ , _ _ _ _ <br /> - <br /> - - :; C.Existing Facility LProposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Ar Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ca.Private Well <br /> ❑ Other • ❑ Other Well,Spring,Shared <br /> Type• capon <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> M. Construction Permit ElPermit Reinstatement NIReplacing a Dwelling •Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor - 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> 0 Major ❑ Minor 0 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 /> 4,i/iw' <br /> it(CriVeCV 503- 0,7- Ivy <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> . l (-rat(_ , IVE Dolph o7 970 7/ <br /> Applicant's Mailing Address . <br /> 9-4-- 2oZ3 . <br /> Si Date: CCB# (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative Aal Authorization to Apply form Attached <br /> G.\FORMSISEPTICIS-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15.3/18 <br />