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_ Application for OnsiteOnly: RE tam <br /> ,,%,„,44.„,„,., • For CityUse <br /> -a=. �� Wastewater Treatment System City of - <br /> Date Received, <br /> MARION COUNTY PUBLIC WORKS - Received by JAN CNI!:2Nc5st <br /> 2019BUILDING INSPECTION DIVISION Zoning byMARv- ®� ��75155 Silverton Rd NE FeeN�UiL®INCPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# /Activity# ICI--00g.)./7 <br /> • www.co.marion.or.us/PWBuildingInspection <br /> A Pro e pwner Information <br /> e P- vNylaCe-ArN <br /> c �q.:4LAtS_YA eld -eb 019- Pl6% 3 3o 2h.00' 2. <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Legal o a Descri tion <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> • • 0-,41 C ro Ve St, Mesinfx\NA 04\ OP— . <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> - C Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: f ( �,�,n. <br /> 0 Single Family Residence ❑ Single Family Residence {Public CA � l�' \V” <br /> Name U <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> • <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D::Ty.Le of Application : _.. <br /> ❑ Site Evaluation ❑ Renewal Permit thorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor Cl 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 /> Pv-Nro\-e\a te(\cL (_)3 302,t1(1 V-L, <br /> Applicaes Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1 <br /> 5 (0 ' C. kS 13r ' * - ': c, <br /> Applicant's M. ''• Address <br /> 411.11. 1" <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the i:i Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G_\FORMSISEPTIC\S-01 ONSIfh APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />