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- p <br /> r <br /> ' /9 co(9X /- 2d . <br /> . . 4.:3H.4:---//// . ria <br /> 1011 Application for Onsite . For City Use Only: r, mate st`m <br /> Wastewater Treatment System city of _,,-:� <br /> ._... �0 _ <br /> Date Received o <br /> Received by 7.,r s <br /> all MARION COUNTY PUBLIC WORKS t r C ,; -2-: c <br /> BUILDING INSPECTION DIVISION Zoning by r.iii , � ; <br /> 5155 Silverton Rd NE Fee `-_ <br /> Salem OR 97305 ""i t ;-"'- <br /> Receipt# <br /> (503)588-5147 Fax(503)588-7948 t;.-C' `�`=-- <br /> • www.co.marion.or.us/PW/BuildingInspection Activity# a <br /> -. - . .- . P._ .. .. _. : <br /> �.' �:. .A Pro erty Owner lnfomiation� �. .. . :.�.: <br /> D i 4), RG-,y 5 CcS per,n De c.r, 541dR 9W3!4 13 -ins-7 <br /> Name -1 Mailing Address City,State,and Zip (Area Code)Phone# <br /> w - .1Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot - Block <br /> cC c Z:h D r S 541-e-1-4. 0 k q-7-3E1' . . . <br /> .Property Address City State Zip Code • <br /> Directions to Property: <br /> - ( -. .: ExisingF...acility/Proposed FacRity/WaterInforaon : <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence 0 Single Family Residence ❑Public • <br /> Name <br /> . Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other • 0 Other ___ Well,Spring, Shared <br /> f <br /> • _ _ <br /> - . ------- D.Tyye ofApph a n -_ : ......__._....._._ —...._...._..--..._ •_._ <br /> gl Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ 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 /> b.,;1 I- "R.,CA,/ <br /> �i-1f3i% CKs. <br /> Applicant's Name—Pleas: ' �i t Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /c ' - <br /> . a - s 1. iffl r _ I WI- (. 3/, . <br /> Applicant's Mailing Address <br /> .-. 1::2-........., '.- _.•AllIMP a-7z- c). rq . <br /> Signature / ate: CCB# (if applicable) <br /> • <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 />