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i <br /> ,0618 <br /> Application for Onsite . - For City Use Only: ' W <br /> Wastewater Treatment System City of F_ -: <br /> Date Received, _4-� ;'' <br /> - Received by : 0 70 : .0 <br /> MARION COUNTY PUBLIC WORKS ( ,,;,. <br /> BUILDING INSPECTION DIVISION Zoning by =•i"-- O [i <br /> 5155 Silverton Rd NE (f)(,) == <br /> Salem OR 97305 Fee _ e <br /> (503)588-5147 Fax(503)588-7948 Receipt# fi!lZ_ <br /> ; Activity# C U�. <br /> • www.co.marion.or.us/PW/BuildingInspection -i <br /> z._ ^...•.. - ._...,._._..._. - _ . - - -- . - - - - - -..CU•. .. - <br /> A:Property Qwner Tnf'miction - � -. <br /> t <br /> • <br /> a-h -P11 Rc, SCCS Dc t i Sr, Sh1 dR '731 9713 -ilis4 <br /> Name - Mailing Address City,State,and Zip (Area Code)Phone# <br /> _ B�Lega�Pro'"`'' Des ii iion: <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot • Block <br /> SS S' ��:,,-) D r S S41.0.., 0k_ c17-3 I lz . - . <br /> .Property Address City State Zip Code • <br /> Directions to Property: , <br /> - ---.-.-_ .. -- — - - - - -r Information -- -- — -- <br /> • . .. . 1. - .C:.Existing:Facility/.Propij�ed.Fad-ilk/Wate� _.........-----..._._.............. ......._ . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> , 0 Single Family Residence 0 Single Family Residenc ❑Public <br /> Name <br /> . Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring, Shared <br /> _ e�o A T �lication <br /> 9Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ 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 El Other ❑ Connecting to an Existing System Never in Use <br /> _ (over 5-yrs old) <br /> ❑ 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 con ct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the ab ve described property for the sole purpose of this application. <br /> ih,;\42,1 Rte, 9I-3f'1 /-. <br /> Applicant's Name-Pleas:. ' o1 t Legibly Applicant's Phone Num er DEQ Lic.# (if applicable) <br /> sc cDavi r Si SQL 7-(g_ 87-31 - <br /> Applicant's Mailing Address <br /> or q . <br /> Signature Date: - CCB# (if applicable) <br /> • <br /> Applicant is the, Owner ❑Authorized Represe tative ❑Authorization to Apply form.Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />