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h 1 <br /> Application for OnsiteOnly: U. �, ! <br /> arlrgpu` For Ci Use <br /> . , Wastewater Treatment System City of M . <br /> Date Received -- 53 n <br /> MARION COUNTY PUBLIC WORKS - Received by " �' <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee L 0r r2 <br /> Salem OR 97305 C r v <br /> (503)588-5147 Fax(503)588-7948 Receipt# c z ' U nA <br /> www.co.marion.or.us/PW/BuildingInspection Activity# • - <br /> i <br /> --- —— _ A Property Owner Tnformatlon— - <br /> &LSon --r. 1;tiq as-51 (-Ivy °JI 1.0 . s .. ,� . . `� . 503-3/, —6766, <br /> J r <br /> Name - Mailinss City, State,and Zip (Area Code)Phone# <br /> B Legal Property__Description ._- =- - — -.___� <br /> Legal Description Tax Lot 'Acreage r Lot Size <br /> Subdivision Name Lot • Block . <br /> S 973l <br /> Property ACity <br /> ddreets� State Zip Code <br /> Directions to Property: <br /> - C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: . Water Supply: <br /> Single Family Residence - ® Single Family Residence ❑Public <br /> 3 1 Name <br /> Number of Bedrooms Number of Bedrooms X Privat <br /> O Other ❑ Other Well Spring, 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 Di 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 /> Applicant's Name—Pleas 'rint Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> S'13 if- .- 1)(31I Way S.. S lrAm)oR x7317 <br /> Applicant's M. �M I g(Address <br /> 344i,tet4)4?7,Y7A4 —1-5---/90 . <br /> Signature D e: CCB# (if applicable) <br /> • <br /> Applicant is the NI Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONS11'h APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />