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\s,tz'tac L\ <br /> 444,83,4,,,.„„17... Application for Onsite 444,83,4,,,.„„17... YY For City Use Only: Date Stamp: <br /> _ ---=------- _-_–.-3. Wastewater Treatment System City of _ <br /> 1111111 <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS • Received by <br /> BUILDING INSPECTION DIVISION Zoning by `�' <br /> 5155 Silverton Rd NE -? ' J <br /> Salem OR 97305 Fee MAY 0 2 2018 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> • www.co.marion.or.us/PWBuildin Ins ection Activity# ;,„ ; e'UN �� <br /> 1 <br /> U 1.D JG INSPECTION <br /> A.-PrObjqtty Owner Information <br /> i,. 6e0V\e 4944 LAeuk or I e►ze7 O12 (4-1303 .h3 'ZL) 2 jJ <br /> Name Mailing Address s.City, State,and Zip (Area Code)`Phone# <br /> :.:- B_Legal PropertyDescnption - _.f:--- - * <br /> . . 4'.._ ` --=:.:_ <br /> . . <br /> p, , "LcpZo <br /> - 'fZ,i prf 2 o—skms:o'- oC 066.01 I,5' <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Pro erty: Gtie.S4- OtA 531Mno crud' - Pf.MA } (LidAA <br /> - ,...., C :IExiting Facility/ProposedFacihty tWaterlnformation :,''..":',7:-';'4e,';'.- <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence Single Family Residence ❑Public <br /> • 3 Name <br /> Number ofBedrooms Number of Bedrooms [Private We,\, <br /> ❑__ _Other ❑ Other Well, Spring,Shared <br /> ,- : D Type,of Application` - u : r r' <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> 1.Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling • . <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary,Housing <br /> El Major ❑ Minor ❑ Other El 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 /> D2h1mS WLe\ c63 -1N3 — 23113 3Ce19`6. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> c 6 —1"K/Kt_ Olt 9-7342 <br /> Ap - ant's Mailing Address <br /> 1-144 Sc i <br /> Siafore Date: CCB# (if applicable) <br /> • <br /> Applicant is the❑Owner ,Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />