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Application for Onsite 1 <br /> c <br /> PP For City Use Only: Del <br /> _a lV E nn <br /> %�_�� Wastewater Treatment System city of V" <br /> 1114—' Date Received SEP 2 4 2018 <br /> MARION COUNTY PUBLIC WORKS Received by7 <br /> • <br /> BUILDING INSPECTION DIVISION Zoning by I�li�r►!=?[(j� �^,®U� <br /> TY <br /> 5155 Silverton Rd NE Fee BUlLDiNG INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# I -- tc. '7-2-5 c' <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <br /> ak <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> _ _ B.Legal PropertyDescription <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> sm _ii., \ cc1 s\ 9-, 1 % Stit\A ( an O ' <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> - <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 /> 3 Name <br /> tiNumber of Bedrooms Number of Bedrooms [21 Private <br /> ❑ Other 0 Other .pring,Shared <br /> . - -- - - D.Type of Application <br /> ❑ 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 /> App icant's Name lease Print Legibly Applicant's Phone Number DEQ Lic.# if applicable) <br /> ( PP ) <br /> po c aQ u v c\r a X1"1 1'D- <br /> 1 <br /> Ap• i ant's Mailing Address <br /> 0 oaf— 5- I k L4LI -1 <br /> Signa- e Date: CCB# (if applicable) <br /> Applicant is the❑Owner &Authorized Representative ❑Authorization to Apply form Attached <br />