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• <br /> . /F e)b Y/e1CF4 <br /> , s,,,m Application for Onsite . For City use Only: ^/� �, Ra}t4 p` <br /> 11114' 9 !EC �� V <br /> ---�=��.1�� Wastewater Treatment System Cityof V 0 <br /> MADate Received <br /> RION COUNTY PUBLIC WORKS Received by OCT 23 201 <br /> BUILDING INSPECTION DIVISION Zoning by MAR COUNTY_ <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> • <br /> w.co.marion.or.us/PW/BuildingInspection Activity# <br /> ww <br /> A Property Owner Information ' <br /> ZIA" VVI/ACL I1188To00.'s RA s t.on off. -x1333 5-03 $oZ Goo <br /> Name Mailing Address City, State,and Zip •. ............_.._: (Area Code)Phone# <br /> E -- « — • -___:..._B.Lega11PProperty Descnption__. <br /> :-- --.: --- --- -----—_. _-.:. <br /> — 1 ac✓eS <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot • Block <br /> I11S$Toa/e✓5 . LI SE. S44-avt OR- . X383 <br /> Property AddressI City 1 State Zip Code <br /> Directions to Property: Eag4 tuft iy br ioMNr) (Z ^4' 110. 1 2Z (pij)e a i1 fC( <br /> C.-Existing.Facility I.Proposed Facility/Water Information,.,. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Single Family Residence DPublic <br /> • 3 Name <br /> Number of Bedrooms Number of Bedrooms kr well <br /> ❑ Other 0 OtherWell,Spring, Shared <br /> D Type of Application......._ ; <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 /> 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 /> 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.s <br /> ar, OAl;/. k o3 50L (no(o3 'SS�.t aS14 45e <br /> �y s I�t�.� aid��s �;��� . <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ( Iler�oje.6 Qa 5 3--4.( v, C3 Ct383 . <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the XfOwner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> GAFORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018DOCX Rev 1/15,3/18 <br />