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?a-6 b bc \ <br /> ,,,, ,,,,�Wf; Application for Onsite For City Use Only: Date Stamp: <br /> — : �i Wastewater Treatment System City of <br /> Mill , <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by —211,1-L"."-:- '' ' . --— p <br /> BUILDING INSPECTION DIVISION Zoning by cal 3 12022 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# � �la s�`' - ° <br /> www.co.marion.or.us/PWBuildingInspection <br /> r Proe OwnerInfrmation \ � ". ';� <br /> :',:S!!!::::::E:;'::- 0® <br /> j Y\ 6,& v1ZI' ' I/dmfitcls�rdSP uw►s��1�/Of 913 '< So� 409 2 4 7 <br /> Name Mailing Address v City, State,and ip (Area Code)Phone# <br /> B Legal PropertyDescription . .,_..__ : , <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address"' City State Zip Code <br /> Directions to Property: <br /> ' C Existing Facility_/Proposed 'acili y/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other 0 Other Well, Spring, Shared <br /> .E_ : .0 R__ >_ .E _ ,_ .<._ .... r__ D Type ofIApplication <br /> ❑ Site Evaluation ❑ Renewal Permit El Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer The Addition of One or More Bedroo s <br /> El Major CI Minor El Existing System Evaluation Personal Hardship , 1e2.J� <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. <br /> h 1c_ 424 oScL 9"'Q)3-1-9?-102 9 . <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ga/ CLNI e Jm iLs SC- /m <br /> Pd S3L it 012, cl. 23 <br /> Applicant's Mailing Addres <br /> c/,‘029,-;_-.I 02S6thL _Iir_ __—_. <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />