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Application for Onsite For City Use Only: Date Stamp: <br /> --- ,0 Wastewater Treatment Systemiing------ city°f nEciENED <br /> Date Received, <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 10 2019 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION(503)588-5147 Fax(503)588-7948 <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> A Property Owner Information <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B. <br /> Legal PropertyDescription . <br /> _.... __ riP <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> K —7 <br /> Property Address City 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 0 Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> El Other Othe tu( �d- Well, Spring, Shared <br /> D.T f Application \ <br /> ❑ Site Evaluation CI Renewal Permit "9/Authorization No a for: t.J19ot.7r vv5(.---.) <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 /> 71, ether—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— • ease Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 319 CS Lo - -- ' ) X17),.., . P2 q2 s' <br /> Apat's Mailing address 1 --q <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ O- .er Authorized Representative neAuthorization to Apply form Attached <br /> G:\FORMS\S <br /> EPTIC\S-01 ONSITE APPL SEPT 201 .DOCX Rev 1/15,3/18 <br />