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/ 1 0031? n 0 <br /> Application for Onsite For City Use Only: <br /> Ci of r A <br /> Wastewater Treatment System ty fl a <br /> Date Received. <br /> 1111111 <br /> MARION COUNTY PUBLIC WORKS Received by �= L N 1 Fifa <br /> BUILDING INSPECTION DIVISION Zoning by U7 r; N c� <br /> 5155 Silverton Rd NE Fee .�L o < <br /> Salem OR 97305 C:t m <br /> (503)588-5147 Fax(503)588-7948 Receipt# --{{ <br /> www.co.marion.or.us/PWBuildinaInspection Activity# C -C <br /> z <br /> A Property Owner Information <br /> 1 <br /> KR✓it W44-ft-425 71/� 41n <br /> g &z ct 5/_uen <br /> Name Mailing Address City,State,an Zi /p 3S/ (Area Code)Phone if <br /> 13Legal Property Description <br /> a <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address ^1 City State Zip Code <br /> / <br /> Directions to Property: 117 EL/nEP4 (5 s/LU&/1p(' tO P 9738 / <br /> po <br /> C;Existinng Facility/Proposed Facility/WWater Information <br /> E 'sting Facility: <br /> 4P.rrooposed Facility: Water Supply: <br /> Single Family Residence �q Single Family Residence DPublic <br /> 111777�����'''"' \ t /17 Name <br /> Number of Bedrooms Number of BedroomsiCKnva[e '` <br /> ❑ Other 0 Other , pring,Shared <br /> _ <br /> D Type of Application '. <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> onstmction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repan Permit ❑ Permit Transfer 9 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 5 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 9 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 /> --24-ntez T. Sd41 6-s3 %o -/%9 _ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable <br /> /15ly 37°4 A' 4 i 54--th-1n ps1 973o/ <br /> App lic 's Mailing ess <br /> i ature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner Authorized Representative ❑Authorization to Apply form Attached <br /> G9FORMSISEPTIC\S-01 ONSITE APPL SEPT 2018 OCX 1/15,3/18 <br />