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: /9 ,- 0J /6c61--- A-eil‘ <br /> 440 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ----0:1 <br /> � <br /> -- ���• Wastewater Treatment System City ofCO <br /> Date Received C z <br /> MARION COUNTY PUBLIC WORKS - Received by 0 I , L u <br /> BUILDING INSPECTION DIVISION Zoning by Z- e'n n <br /> 5155 Silverton Rd NEFee 0 <br /> Salem OR 97305 <br /> # � �`0 1\D <br /> (503)588-5147 Fax(503)588-7948 Receiptsus <br /> • Activity# -O <br /> ww.co.marion.or.us/PW/BuildingInspection C <br /> w - <br /> Z <br /> A PropertyOwner Information -`: <br /> 4 n-Ji,/1 5. 5h-1.14-_5 c.?9 96- 14.e-- 2. Pil/Y.4S.e: JU3L;m/T a� s j-r z — 8'7 <br /> Name _ Mailing Address City, State,and Zip .. , (Area Code)Phone# <br /> B Legal Pio P_e Description, �_ <br /> .. _rt <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name 1/ of • •lock 9. <br /> C ‘a/ /-01;n-1 7d c‘g ,..=ce Z 4 06e4--- at <br /> Property Address City State / Zip Code <br /> Directions to Property: <br /> - C Existing Facility/Pro osed Facile I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single Family Residence 0 Single Family Residence ['Public <br /> LA 1 Name <br /> Number of Bedrooms Number of Bedrooms A Private <br /> ❑ Other • 0 Other WeV,Spring, Shared <br /> D e of ApPlicalion <br /> ❑ Site Evaluation ❑ Renewal Permit ,E'Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer Nr The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation U 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 /> o to enter onto the above described property for the solepurpose of this application. <br /> Department of Environmental Quality,permission p P rty <br /> -.-iz,./,5 :5;:m.15 ,6`'03 - ya.S - /89A <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> i <br /> • <br /> Applicant's Mailing Address . <br /> /L..... ...„,____ ,.,c>., .- __,..' , --?//LT/"/7 • <br /> Signature Date: CCB# (if applicable) • <br /> • <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONS11'b APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />