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• <br /> ,,,, k,, Application for Onsite For City use Only: Date Stamp: <br /> --7.�3. Wastewater Treatment System City of FK Fa <br /> Date Received a <br /> 11111' 1VIARION COUNTY PUBLIC WORKS Received by �O VO <br /> ififil <br /> BUILDING INSPECTION DIVISION Zoning by zZ t ' <br /> �OriND o <br /> 5155 Silverton Rd NE <br /> Fee <br /> Salem OR 97305 Receipt# n Z <br /> (503)588-5147 Fax(503)588-7948 pFR <br /> www.co.marion.or.us/PWBuildingInspection Activity# 0< <br /> Z <br /> A Property Owner Information <br /> fit' oh li hri / (-‘te( & )53q Siv � <br /> , s r� , St:1vt�-I�s i , (�q738! -Ll Z <br /> � <br /> Name _ U Mailing Address City,State;and Zip (Area Code)Phone# <br /> B.Legal Pro a Descrp tion <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name . Lot - Block <br /> I5'( '1 5,)Te- Tel II5 it N S11v^ -Eon o K 97381 <br /> Property Address City State Zip Code - <br /> Directions to Property: - <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence " Single Family Residence ❑Public <br /> L.1� Name <br /> Number of Bedrooms Number of Bedrooms V Private W ei <br /> ❑ Other • 0 Other Well,Spring, Shared <br /> D.Type of Application , <br /> ❑. Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> gi Construction Permit El Permit Reinstatement . ❑ Replacing a Dwelling . <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation El 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 /> El Other-Please Specify <br /> • <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 /> e <br /> . .. <br /> ogd4 Fink 563 - 2g1 -yy`7Z <br /> A hcant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PP g Y PP P <br /> ' 15 3q S i'lve r- Fas 1 o Ki E - i 1 kic-itie) 1 (K 97381 <br /> A 'cant's Mailing Addres / <br /> #9////20,4 Z-. . ' <br /> Signature Date: CCB# (if applicable) <br /> • <br /> i Applicant is the Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br /> GAFORMS\SEPTICIS-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />