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1 g ' (AD 5'57 LA <br /> Application for Onsite For City Use Only: Date Stamp: <br /> -----'-- -w--_---.1 Wastewater Treatment System City of <br /> mig <br /> Date Received, �/� <br /> MARION COUNTY PUBLIC WORKS - Received by EC E I] V FEni <br /> TS, <br /> BUILDING INSPECTION DIVISION Zoning by JUL 17 2018 �_.J <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION O N COUN <br /> IBJiTY <br /> • <br /> www.co.marion.or.us/PWBuildingInspection Activity# BUILDING INSPECTION <br /> A Property Owner lnformatiou <br /> k - <br /> C d Ph, ci ' -- Lig c 541 i )-- itA r4,r-- ic :-� <br /> Z G q -j 4, c-; ,(v <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B1 Leal Pro e Desei tlon _. <br /> Legal Description Tax Lot - Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 9.`12 t v �„ A -' L L . " s, \ OA Ci-7007.— <br /> Property <br /> 7 oProperty Address City State Zip Code <br /> Directions to Property: "l l 2-3 i?-E Avi,-`_,6,l'. LI'\ - Iv <br /> - C Existing:Facility/Proposed Ficilitirt WaterInform#tion_..... ,..' .... ..�: <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single Family Residence 0 Single F ily Residence DPublic <br /> 3Name 4 <br /> Number of Bedrooms Num er of Bedrooms R Private —t-1\ <br /> ❑ Other ❑ Other Well,Spring, Shared <br /> D <br /> Type:of Application ' ,_... � ........v ._..�::. _...._... ..__.... ._._._. <br /> 0 Site Evaluation ❑ Renewal Permit "Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement : ■ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer I_ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> PAlteration 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 /> '&41'1.444 b4� '57)3l 3 q8-./ /X4 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> ./-All_/ =1�ii . - 7/1. 7/I i ? . <br /> Signa ilrf Date: CCB# (if applicable) <br /> Applicant is the7wner El Authorized Representative El Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\//S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />