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_ IO - 002.0(0 ci-tl, '"ou A��t4 <br /> *k ` • Application for Onsite For City Use Only: Date.Stamp: <br /> • <br /> —"1---'-- = „ Wastewater Treatment System city°f — 1 <br /> Date Received, lECEWE D <br /> MARION COUNTY PUBLIC WORKS • Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 11 2019 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> • <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> _ _ A Properly;Owner Information ' <br /> 0.esse S\netivr PO Box IW1 Scotts 1`A\\\SCYR cniT so2)-m -11D\q <br /> Name Mailing Address City, State,and Zip . ....._.._.. (Area Code)Phone# <br /> B Legal Propre_. Descri tion <br /> NC9-ESci.00, MSX-* X00195610)Ho-\�ID 0--11 (OS0O -3Zo aCras ` bio <br /> Legal Description 2-'52-322_ Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block . <br /> • <br /> 4-1 r2A0 iC1 r Yoob LP NE Scotts n\\S DP_ 912,-.5 <br /> Property Address City State Zip Code • <br /> Directions to Property: 1-\\J\5\) 2\`2 �loc-c c' Ov.'S CNQ r oV\1 Q.. �-t 01)W •K��cj'1.a- <br /> F-Zd y ip A-,C3 rn�12Q1•\1QQ r \�- On-to v:),(:-\ax- Knob Look, ,r) G -k -2A-0\\:12_s l\r,o cmt.lnt> <br /> sada <br /> C Existing Facility/Proppsed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> (single Family Residence ►0 Single Family Residence ❑Public <br /> 1 Name <br /> Number of Bedrooms Number of Bedrooms io Private Wei <br /> ❑ Other 0 Other Well,Spring, Shared - - — <br /> D Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit gAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . CI 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 /> kYi 5-c-i 2 S -c-1 A- <br /> Otsssz, Sh t\syr 5o3-219-D-2tio Pl <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> `Po ')o X A\-1 . Se \\A-\\\S, 0'R "\-12-FD <br /> Ap.licaut's M ' . Address _,_1 O _ \p` <br /> If y . ire-aa y <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the❑Owner 0-Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSf1'b APPL SEPT 2018DOCX Rev 1/15,3/18 <br />