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• <br /> . • <br /> co 0 1 <br /> Application for Onsite For City The Only: -I—.'pate Stamp: WU <br /> _ .-- Wastewater Treatment System City of . P._ ci) 0). <br /> FAO g <br /> . _,., _ <br /> aii <br /> • <br /> MARION COU1sITY PUBLIC WORKS - Date Received <br /> Received by 1 ,-7 <br /> z 0 cD ,==, <br /> BUILDING INSPECTION DIVISION Zoning by 0 T2 <br /> 13 c:2 <br /> 5155 Silverton Rd NE Fee ,r `•-- a bz T H <br /> Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948 ReceiZ <br /> pt# - I--i <br /> www.co.marion.or.us/PW/BuildingInspection Activity# Z <br /> 1.. . •1*,:.•._•.:.::. ..... .,:...'..:.::. --... .../, i::..... i'.:..-::''..-.:* '..: •" •!....f. ...:i A.Property OWner InfOrniafkin.-- . .-.7: • ..,-.:. 1: :':: :--:• :: . 2..,•:. .:.-!•:-::.7::• "-:.':,.: :..I <br /> bat Comb. 1(P3(1 Oettkletiftfik Rd S6 Datab be. 0131'1 .503- 3b -314 <br /> NameMailing Adgresi City,State,and Zip . ' (Are,a Code)Phone# <br /> . r. . .• . . - <br /> L_ ::c. . . •. .2_- • !.- :•-• -'- : •: •'.' • . 14:Legal Piop:Orty-Desaiiigigi .-.. . . .... • • : - . - : ::- z .... : <br /> Legal Description Description Tax Lot Acreage or L9t Size <br /> . . <br /> Subdivision Name : . Lot - Block <br />, • • <br /> 1 1,..3(i bride C11Ct Oa Skim ip." 6113 1.-7 ' <br /> .Property Address City State Zip Code • <br /> Directions to Property: <br />, • F•27. : - ... •."•.::r;'::!..•"- :. .:::. •:.'';C/'Existing FaCffity i Pr-044104 FaCilitk/•WaidtIrifoitaailoii77777:— Tr' 77-77777 <br /> g Facil' : Proposed Facility: Water Supply: <br /> Sin: e F.."y Residence 21 Single Family Residence OPublic • <br /> 4 •V Name <br /> . '.um..er of Bedrooms Number of Bedrooms .7 Private W(111 aor ed <br /> • <br /> 1 Other ' El Other Well,Spring,Shared <br /> ig1 Site Evaluation D Renewal Permit []Authorization Notice for: <br /> El Construction Permit 0 Permit Reinstatement . 0 Replacing a Dwelling - - <br /> D Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major D Minor El Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major EI Minor 0 Other 0 Connecting tO an Existing System Never in Use <br /> . (over 5-yrs old) <br /> El Other—Please Specify <br /> • <br /> If the required fee and attachments are not included with this application, it will be returned toycnt 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 /> REAV it, Coo rn b 5 503-K3o-314i <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> '1‘49344 13mile Orttu—. i2d1 St 51A1enq OR. 0113n . <br /> Applic...• s Mailing Address <br /> / 9-10-197 • . <br /> Sign. e, Date: CCB# (if applicable) <br /> • <br /> Applicant is the KJ Owner D Authorized Representative 0 Authorization to Apply form Attached <br /> G:\FORMS1SEY11.0S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 . <br />