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. /96ZfO� <br /> . Application for Onsite . For City Use Only: C I r31- <br /> - U, 1 Wastewater Treatment System • City of0> TH <br /> ° <br /> MI Date Received, <br /> •MARION COUNTY PUBLIC WORKS Received by <br /> 6:o 3:1 n <br /> BUILDING INSPECTION DIVISION Zoning by 2 4 ' M <br /> 5155 Silverton Rd NE Fee "0 0 ' ' <br /> Salem OR 97305 • fli C c®�® <br /> (503)588-5147 Fax(503)588-7948 <br /> Receipt# 0 Z <br /> www.co.marion.or.us/PW/BuildingInspection <br /> Activity# <br /> Z <br /> A ProQertyDwernformtlnno _ <br /> Pccrw - Po 3iox ' 71 S 'VDR q 3s <br /> SOF 71� 1oI <br /> t` <br /> Name - Mailin Address City,State,and Z (Area Code)Phone# <br /> .. B i"-:6i al Pro a Descri tion t ---.'--:::.;-7.i.-;'..!.':::::::::7-1....: <br /> -- =- - ---- - <br /> G 0- a ' -S S 'i 1 F -bo 6 I3 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> 1 <br /> • 7.l a . L f r S alai;hi. -yC2R__ 973 e.,i' <br /> .Property Address City •J State Zip Code <br /> Directio s to Property: /Led Li 2 l'L/C,/vc1N'/ !l L5�eJ) Z,1 c j c r L c\ SG. G( ®prtoe <br /> G Existm Facilt . /Pro osedFaciltYa /-Water information <br /> P <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence X Single Family Residence ❑Public <br /> Name . <br /> Number of Bedrooms Number of Bedrooms A Private ' ' C. <br /> ❑ Other 0 Other /Fri,Spring, Shared <br /> D Type of Applicairon :r_......- _.. ...._ _. <br /> ❑ Site 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 ❑ 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 /> ck-- La- \?e.)-e'rIS S03 70 be 30 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 0 \‘1, _I 1e, i4 • o„ •• - - _s <br /> A plicant's i.i ailing A.. e4 <br /> 1 no <br /> 1- \ 3-A1 ✓'b • <br /> Signature Date: CCB# (if applicable) <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 />