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Fir— . <br /> Application for Onsite For City Use Only: Date Stamp: <br /> a--3 City of c Wastewater Treatment System I i -002,.5 <br /> s��6 Date Received D C E O s <br /> 11.111 MARION COUNTY PUBLIC WORKS - Received by v <br /> INSPECTION DIVISION ZoningbyE in <br /> t J <br /> BUILDING �A� 2 5 2019��=-�� <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Reeeipt# MAR101y COLE 7 <br /> (503)588-5147 Fax(503)588-7948 BUIL®1n9G l NT' <br /> www.co.mar• ion.or.us/PWBuildingInspection Activity# �$�EC7-1O1a l <br /> 31)) _�. � A Pr�erix wner Information <br /> -Js L2S I F P San 3 Ce 9 11 5 • n%Sg <br /> Name Mailing Address City,State,and Zip (Area Code)Ph # <br /> Legal Proertyx77escription <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot • Block <br /> 1JZ5 p fyvi-Viarka ?d Bohm w... 9-1511 . <br /> Property Address City State Zip Code <br /> • <br /> - <br /> Directions to Property: <br /> - , C Existing Facility/Proposed Facility/Water Information ...... _... . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence Of Single Fa pily Residence ❑Public c Ol'y <br /> i"71, L <br /> NumberName . <br /> (!�ofBedrooms Number of Bedrooms Private <br /> ❑ Other • ❑ Other Well, Spring,Shared <br /> D Type of Apizlication <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . iv"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 /> • <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 /> —PleaCle,1-e-laus., 66-5. 5o .1 L . <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ) <br /> 1425\ f uvRaat. eci Satim CP °11511 <br /> Applicant's Mailing Address <br /> C' ) •ZS•I9 . <br /> t...ature Date: CCB# (if applicable) <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 />