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• <br /> • <br /> • t°► -6o ' Flu- p <br /> Application for Onsite For City Use Only: Date Stamp: <br /> - ad�k4n41' <br /> --------'-'7- ---,7-. 54. Wastewater Treatment System city of _ --1 . <br /> Date Received E C E IIV E <br /> MARION COUNTY PUBLIC WORKS - Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 2 3 2019 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> Receipt#(503)588-5147 Fax(503)588-7948 BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A,Property Owner Information <br /> &:Anent 2 Dc'.n eA .(lo +der' %333 2ecslrfkr.e,ije SE QMn, Oa_ 611306 ( 503) 585-0°119 <br /> Code)ode)Phone# <br /> Name _ MailingZip Area( <br /> Address City,State,and .................__..�_..._...._ ..:_...:_..�._.._._ ._._.:..._._.._.._._._..._:.._.. <br /> Legal Pro.Per�t' escription ; = _._._., <br /> - e-� - wu nS 19 — IT_ 3..__._ e 3 35 A cool : <br /> Legal <br /> Description <br /> Tax Lot <br /> Acreage or Lot Si <br /> e <br /> SUnnvvSe8e. UiA- VornAS -4\2_ . 5 . . <br /> Subdivision Name Lot - Block <br /> A 333 Pte.ds+cmz Ae Se Sale r►-, O►2 cl1306 <br /> Property Address City State Zip Code <br /> - <br /> Directions to Property: <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ;4ISingle Family Residence ly Single Family Residence ❑Public <br /> Lt 3 Name <br /> Number of Bedrooms Number of Bedrooms 1 Private U.)Q,1 1 <br /> ❑ Other ❑ Other Well,Spring, Shared — — <br /> D Typ.9 of App hcation <br /> ❑ Site Evaluation ❑ Renewal Permit 1,.4 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 LI 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 /> • <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 /> E54\ el' orlcnndeAe (503 ) 586 -0cika <br /> • <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> A s3 ..e 8 s*tsn-e., jAwe. SE 5a. 1 a i2 -�00.4 <br /> , <br /> Applicant's Mailing Address <br /> C,,‘-r-tv.....1,...-- In �.�_ dI IZz 119 . <br /> Sture 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 />