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j ,60/ — /,4j, <br /> Application for Onsite �t�st4mp: <br /> ���r�, �?';,�,,,,�. pp For City Use Only: <br /> : �. c, Wastewater Treatment System City of <br /> Date Received G mn <br /> ........._ <br /> iiii <br /> MARION COUNTY PUBLIC WORKS Received by �" �/� <br /> 0 <br /> BUILDING INSPECTION DIVISION Zoning by t�C� CO V\ <br /> 5155 Silverton Rd NEj Fee t' <br /> Salem OR 97305 � O G;n <br /> (503)588-5147 Fax(503)588-7948 Receipt# Ci) <br /> Activity# '1 <br /> ww .co.marion.or.us/PW/Buildinginspection y„C-• T, ,� <br /> w <br /> `A.Property Owner Information <br /> :"S / h� ,54 (3Sc.�nAyule,,c,2I'�`1 - SA.2.m-,o .01730,5-- 3-7/a a23 <br /> Name // Mailing Address' City, State,and Zip (Area Code)Phone# <br /> _:_ .__ __-_ -.. ___-- __:____ ..:_ :.�—B LegalPrbpertyDescnp m. • . <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 /> - E' C Existing Facility/Proposed Facility/WaterInformatlon <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single F ily Residence '0, Single Family Residence ['Public <br /> del\ Name <br /> Number of Bedrooms Number of Bedrooms V Private <br /> ID Other EI Other Wel.Spring, Shared - — <br /> D e of A lication <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling . <br /> ❑ Repair Permit ❑ Permit Transfer SI The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ 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 /> ❑ 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 /> Se_SQ ,b3-7 h-2232 •Applicant's Name—PleasViok\ <br /> int Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 5/1'13 ClhA.y Utt, RA (L . <br /> Applicant's Mailing Addfess . <br /> 1i 1Q (99.106/a0 tei . • <br /> Signa 0. ‘ I k Date: CCB# (if applicable) <br /> Applicant is the rill Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSfl'h APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />