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NO � 60� <br /> Application for Onsite For City Use Only: Date Stamp: <br /> • - -:, " Wastewater Treatment System City of ,, '! (� - r -1‘: <br /> y Date Received, I� I ` / <br /> } <br /> Mill MARION COUNTY PUBLIC WORKS - Received by I 1I NOV �� <br /> BUILDING INSPECTION DIVISION Zoning by °`� 2 Q <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 "',,=.R i�,N OOUkTY <br /> (503)588-5147 Fax(503)588-7948 <br /> Receipt# s r-' 1C !i',1 )--)7-7 r;DN <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> _A Property_Owner Information. <br /> j, hr J :e k7y.1�7 &,a /i, i _ bons, 0r, q . 5°3-g f-'�i-2O� <br /> Name J _ Mailing Address City State and Zip (Area Code)Phone# <br /> . :..__.B Legal Property Description- ---=- :. .. -- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> Property Address �y Ci tate �j Zip Code <br /> Directions to Property:�� 0 c ��� f 4'LL, (i/ j3, Vn K) (1�. /-ITl1, <br /> _ , . . . . . C .Existm Facility/Proposed Facile /-Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, 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 /> ❑ 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 o Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> V ar �h Yl, 5'03-8g 1 -q-(,)2 <br /> Applicant's Name-Please Print Legs ly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Fay 9)6.----7-, 61 Ci.frl a-J 0110 <br /> Ap is ailin!AV ess <br /> ji /r /A <br /> iivature Date: CCB# (if applicable) <br /> d <br /> ,4Applicant is the❑ Owner uthorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />