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lot- D4 <br /> Application for Onsite Date Stam <br /> au��uq'�. - pY For City Use only: P: <br /> .-7--" :-->;5"--='-'7Z-=---3 Wastewater Treatment System city of - <br /> Date Received D ECEIVED <br /> MgMARION COUNTY PUBLIC WORKS - Received by �l l.. <br /> BUILDING INSPECTION DIVISION Zoning by MAY 0 3 2019 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# �����f� INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A ProPerSy.Owner Information i_ <br /> --r2ct a.,k& boy\Kie VbPAl_rtutYliti. ‘4535 etnne,r Plk_SE S-E-w4o►n OiP 113%3 503-(131-iLleig <br /> NameMailing Address City, State,and Zi (Area Code)Phone# <br /> B Lega_1_Pro.2erty Descri -hon__;—__._ : <br /> �'i2 1-7-nn � 3.t D n q 1 SAI o' 9Z <br /> k . - - ____2,_,._:....: <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot - Block <br /> 14535 SpQ,inreA 04 SF- S-4 VM+o1%. De- c1-13x3 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> : C Existing Facility/ProposedFacihty/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single Family Residence V] Single Family Residence ['Public <br /> • <br /> 3 LA <br /> Name <br /> Number of Bedrooms Number of Bedrooms jit Private <br /> ❑ Other • 0 Other Well,'•pring, Shared__._. <br /> D Type of Application ' <br /> ❑ Site Evaluation ❑ Renewal Permit 4A thorization 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 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 /> x-535 -5' e-rlrle la Sr- a1--4fo-it - ole cOge <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the 1 Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\PORMS\SEPTICIS-01 ONSI1'b APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />