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• <br />li - <br /> • <br /> VSs_�q-ooa2.5O -A01 r+ <br /> .,,, ; ,,,,� Application for Onsite . For City Use Only: Date Stamp: <br /> "'" <br /> —=—=,,= Wastewater Treatment System City of <br /> Date Received 111111111/ MARION COUNTY PUBLIC WORKS . Received by IIECEIIVEn <br /> BUILDING INSPECTION DIVISION Zoning by MAR 2 7 2019 !G <br /> 5155 Silverton Rd NE Fee MAR F i n N COUNTY <br /> Salem OR 97305 Receipt# UILDING INSPECTION <br /> (503)588-514'7 Fax(503)588-7948• Activity# <br /> www.co.marion.or.ns/PW/BuildingInspection <br /> a <br /> .,- _ _.. . . ... ,=-'�f..P�[opeity,Ovtiner_Inforrii•tion� • -. •-..- .1 <br /> '-- Ob e- -r a:✓... c o `e i 5_)) )/ ,If" on tlg, &f <br /> Name g A City,State, Zip_ _ .• (Area- P -_ <br /> • <br /> .: . B <br /> ddress � <br /> •Le-alPrope k]es tion: • <br /> 2 /' <br /> .�_... _. r= - <br /> Legal Dese,.iption Tax Lot Acreage or Lot <br /> Subdivision Name Lot - Block <br /> • <br /> Property Address �/ �p ( City /p �J .— State Zip Code • ' <br /> Directions to Property:q( / 6 0 ),, at, a AN Iv,, r% - 6r2- 093Y/ . <br /> v . <br /> — <br /> — <br /> ,1 . . .. . ..._ :. _. E.>�nsting <br /> FacihtyLX'rmo <br /> oseu <br /> dFaciltty l- aterliforination : - .• - -_ . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> pimgle Family Residence Single Family Residence DPublic • <br /> • Name <br /> Number of Bedrooms Number of Bedrooms —rivate <br /> ❑ Other 0 Other We .pring, Shared <br /> - - P. • •• • _. <br /> - - • -- ....:D!:.._.' eofA.PP licatitin.. -- �-- _._..._._ .--.. .. <br /> ❑ Site Evaluation ❑ Renewal Permit ■A 1 thorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement 1 Replacing a Dwelling . <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ' ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review ❑ Temporary Housing • <br /> El 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 /> P7Y73 ) F6 . <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Aplicant's Mail-i g Address <br /> pignature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached • <br /> G:\FORMS\SEPTIC1S-01 ONSITE APPL SEPT 2018DOCX Rev 1/15,3/18 <br />