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,i/— U ra33/—/° r <br /> 0 <br /> Application for Onsite For City Use Only: o D p: <br /> - % Wastewater Treatment System city of IE <br /> z� <br /> r <br /> Date Received <br /> O Tfil <br /> MARION COUNTY PUBLIC WORKS Received by ZZ � <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee crl <br /> Salem OR 97305 nZ - <br /> (503)588-5147 Fax(503)588-7948 Receipt# TI� <br /> FRI <br /> w ww .co.marion.or.us/PWBuildingInspection Activity# O <br /> A Pro e Owner Information <br /> . ZW act Cvr'P <br /> Name ,Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Property Descnption' , . T <br /> _.��t� -e-�1 —0c'_ -orc�� ram© <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 9/g i 1lbrz Friei ed I bra; 01Z9-73g <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Existing Facility/Proposed Facil ty_/,Water Information; ___.._ ._g__ <br /> Existing Facility: , Proposed Facility: Water Supply: <br /> ['Single Family Residence XSingle Family Residence ❑Public <br /> _-3 Name <br /> Number of Bedrooms Nmber of Bedrooms <br /> * Private 5WAP OD <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D e of A hcation <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> K_Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> itif,, ajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> El Iteration 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 /> VII-Y2 L T J %31�5 5a fie c/9 c <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> / 9W 37 AvE #it) � wi�<m 1o/e r7304/ <br /> Appr is Mail' dress <br /> : - -iPt%L..--- <br /> S ature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner Authorized Representative11 - ❑Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />