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R - iba°►5(L0 <br /> .,, `,pro„4,h,` Application for Onsite City Only: Date Stam <br /> r of <br /> Use <br /> ~ mg Wastewater Treatment SystemCity C [I 7{ <br /> Date Received, <br /> MARION COUNTY PUBLIC WORKS Received by - 3 <br /> BUILDING INSPECTION DIVISION Zoning by AMR 2 2019 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILD,\IG INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> — A Prop p-iOwnerAmt• 5rmation <br /> ty . <br /> frb ie <br /> 34)1 <br /> fit,H pi TE t ..-:-_ __,_!_-,,o.,__ _ l .— 0 6 . <br /> Name ( - Mailing Ad.' s , State,and Zip 77 — Area Code Phone <br /> _±-_-_-__-_,-__- __ _.:::_ <br /> B.Legal Property`Descnp.on _ _,_:._.-17 <br /> _ ..._ ='--__-:._. - <br /> ?_? 14.1. __•3 �� / , 400, Iwo/TO o /7_ . -f- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block . <br /> 1:2 9 7.1 ,3—e A< IL/L.,y F sr -i-CP•e4s_svit.) OR 9?..3s� <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Existing Facility/ProposedFacllity I WaterInformahon <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence ❑ Single Family Residence ❑Public <br /> .� Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑ Other ❑ Other Wel Spring, Shared <br /> D.Type of Apphcahon <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 the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of thiof s application. <br /> 4-`5- c . ..0 611-9V-oTa‘ <br /> Applicant's Nam Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /,,?9 7 �P. �/w y E S / -�-e-Q•-:(04) (Tj 9?35.z._ <br /> App -.sAppifil Mailin e ` <br /> Sign• e Date: CCB# (if applicable) <br /> • <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 />