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, Iaa6-Y6,--otie_ . <br /> . . <br /> .„,44k„„,, Application for OnsiteFor City Use Only:y: 0 Date Stam •� 0 <br /> —= "f» Wastewater Treatment System City of m. <br /> Date Received 0Iwo T <br /> MARION COUNTY PUBLIC WORKS - Received by Z <br /> BUILDING INSPECTION DIVISION Zoning by °Z. O Tfi <br /> 5155 Silverton Rd NE Fee z C `P a) <br /> Salem OR 97305 0 `� <br /> (503)588-5147 Fax(503)588-7948 Receipt# a <br /> 0 21 <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> iIs <br /> id,i t VC!h A Propetty-OWner Info tion <br /> iVn 7i � -E r`k112S- e i i O'o:Jr'''e Sole CTC- Q 20S <br /> o602jq <br /> Name _ MailingAddress City, State,and ZipArea # <br /> . :_.:..._.._.._.. - B Legal Property Description ... <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> f4-k.co1( ;f <br /> pfa ,e At\ VE SOW art- q 7fc 2 . . . <br /> roperty Address Ci State Zip Code <br /> Directions to Property: nor' c, e pro For T� - <br /> _ . , . . _ ' C.Existing Facility,/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other • ❑ Other Well,Spring,Shared - -DTyps of Application ....: <br /> NSite Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El 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 /> l `pilc.-, <br /> 4--., 111144'-, <br /> CSo3is/ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 9'9Z8' /-140,v e `l pr,t e 2 0 I!✓r ,,i l ii- 02 q 7 yc.f' <br /> Applicant's Mailing Address <br /> 21-1Signati � <br /> a -14- 4L .,(4- <br /> _,,. , <br /> Date: • CCB# (if applicable) <br /> Applicant is the Xpwner Authorized Representative El Authorization to Apply form Attached <br /> GAFORMSISEPTICIS-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br /> I <br />