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19 <br /> -0 <br /> 036i2_ <br /> - 4rrt� <br /> Application for Onsite For City Use Only: Date Stamp: <br /> aU �;;;0:4,H�1 <br /> -- Wastewater Treatment System City of r, i , <br /> Date Received,T._ — �--_ �' <br /> MI MARION COUNTY PUBLIC WORKS - Received by ., _ , --1) <br /> BUILDING INSPECTION DIVISION Zoning by 2 5 2019 <br /> C, <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww.co.marion.or.us/PWBuildingInspection Activity# <br /> w <br /> r - :',--_•-• :-....-_-_:i:::A Property Owner_Information _ <br /> BR ()r x ID 7 gii ", 0) SE I htnns u;1log 6R <br /> Name Mailing Address City,State,and Zip q.7a —(Area Code)Phone# <br /> r' r.;,' _ _....:.: B Legal Property_Description---- -- __-- <br /> Qiru 328 DlSOD :2_..mac_ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 732SP10574 Mi/VITV_19± hi DR q7323— <br /> Property <br /> roperty Address City State Zip Code <br /> Directions to Property: <br /> .:•- C .Existing Fac111 /Pro-.osed Fty <br /> ac11i ./Water Information..... <br /> Existing Facility: Proosed Facility: Water Supply: <br /> likiSingle Family Residence Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms NumbLeIr of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well, Spring, Shared <br /> ._.._ D TypeofApplcation •1 .... ._..._ ..__ ,....._. <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer The Addition of One or More Bedrooms <br /> El 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 /> • <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—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 10 574 iii 1 i/C r-v 1 R SE, A ix\Rks u i L I Q 1 O R 17 3 2 S <br /> Applicant's Mailing Ad ess <br /> c/—/6— /47 <br /> ature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONS11b APPL SEPT 2018.DOCX Rev 1/15,3/18 <br /> 1 <br />