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- <br /> oil -66d ;a ()_ . <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Jd�ypp1 - <br /> Wastewater Treatment System City of <br /> IIIIIII Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> • <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> �- . . ' :; A.Pie e Owner Information <br /> • 3gt / �5 4 (79eecr L^i a+le5 DR', ?7YZs' 28 c2134( ' <br /> Name Mailing Address City, State(and Zip (Area Code)Phone# <br /> - : -B.Legal Property Description - --- ---- — __ ---.... <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block . <br /> 174 (22eci 6A4ei3 o Q q 93 yC{, <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> (— -- ---- — 7 C.Existing Facility 1 Proposed Faclity l Water Information" _.... ._._ ...._ ... .... ......' <br /> Existing Facility: Proposed Facility: Water Supply: <br /> (Single Family Residence , Single Family Residence Eei<lic C/ 6 g,4,s- <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring, Shared --_ <br /> :..:D.Type of Applica i in , <br /> ,Site Evaluation ❑ ,enewal Permit No ` s rization Notice for: <br /> ,€onstruction Permit L Permit Reinstatement . Fi Replacing a Dwelling <br /> Repair Permit (-1 Yermit Transfer 1 The Addition of One or More Bedrooms <br /> Major ❑ Minor [j Existing System Evaluation ❑ Personal Hardship <br /> El 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 /> cfa5-01( - (WC e <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /94 C?ed- C.AJ C,i-te sr ae. 973c((P <br /> Applicant's Mailing Address <br /> .4., .,......„, 0_,..),(---- . <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative El Authorization to Apply form Attached <br /> G_\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018DOCX Rev 1/15,3/18 <br />