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( e7,6 03sz Z' Go <br /> .400414,,477. Application for Onsite . For City Use Only: Date g I-L <br /> --.-..--r-=z- i Wastewater Treatment System city ofDate Received <br /> G)G n <br /> MI �` <br /> MARION COUNTY PUBLIC WORKS Received by w( CSI � U <br /> BUILDING INSPECTION DIVISION Zoning by -0 0 o <br /> 5155 Silverton Rd NE Fee 0 C o i <br /> Salem OR 97305 =i <br /> (503)588-5147 Fax(503)588-7948 Receipt# ®"N LV_ <br /> www.co.marion.or.us/PWBuildingInspection Activity# Z <br /> ------ _. --- --- -- - A Property_Owner Information-- - . .. - .- =-- _ _._. <br /> icK 4- LirAne IOW ("i0 S. PA- a .'E Sr. Pc LtL) 6� Co3- 5so-IOZS <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> - _: _B Legal Pe <br /> op 'Descri 'on <br /> r f.? 7 __.. d ohwo 0ioo- ._ _ . ._ /, c t <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> • <br /> 7 (068` ckampoej 12d. !J( ST,( A-AL G(Z OK_ 911 <br /> Property Address . CityState Zip Code <br /> Di ctions to Property: Fro Sd.eIv\ - W. 2 vi t !- -) .41) P a r* 11A ,(L <br /> ru+ ti ST.24 t <br /> K. Oh�.mpo9 rr Rd /+ppra.i,vv.k y Z Ir.tkes i`as`i- Name oft ►L right. <br /> C.Existing Facility/Proposed Facility/Water Information . • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> (,Single Family Residence a Single Family Residence ❑Public <br /> t 3 Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑ Other ❑ Other e S rin ,Shared <br /> D Type of Application <br /> ite Evaluation ❑ Renewal Permit ►:A i orization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement : ►2 'eplacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ■ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor El E• xisting System Evaluation ❑ Personal Hardship <br /> Y to .-•n Permit ❑ R• ecord Review El Temporary Housing <br /> N 4 ajor ❑ Minor ❑ Other El Connecting to an Existing System Never in Use <br /> - / (over 5-yrs old) <br /> fill . - ( ❑ 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 /> RIa Tuiepen �L`timeRf (, - sso- iozs <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 340s RA-9 ee 11 Rd. uE SAPAuL, ai2__ (37137 <br /> Applicant's Mailing Address <br /> ` - 4b 5 - 13 - 1q/ . <br /> SignaturC\`J�� cDate: CCB# (if applicable) <br /> • <br /> Applicant is the ` Owner ❑Authorized Representative ElAuthorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />