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• <br /> 03 <br /> r <br /> Application for Onsite For City Use Only: DL p> MI <br /> �—�`. Wastewater Treatment System City of 0 Z 33 0 <br /> - ,tea. <br /> Date Received Z �—` M <br /> • , (� <br /> 1 111111MARION COUNTY PUBLIC WORKS Received by I]0 N <br /> BUILDING INSPECTION DIVISION Zoning by M C <br /> Silverton Rd NE <br /> 5155 Fee =-I ��� <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt#• z )) <br /> www.co.marion.or.us/PWBnidingInspection Activity# <br /> ': •: ; : erty+'Own a <br /> L_:.._ n > .Prop er InfOrlll ti0I1 <br /> Pelt 4'6ON+"A F 4A s ...• 'o 80,‘ 13131,40436-) Ox- 41 735 1 V3 V3 .Tit 7 f <br /> Name - Mailing Address City, State,and Zip Area Code Phone# <br /> .. <br /> . .. ,. . ..: _. .*B. eriptl ,. . <br /> I;e Prop., Bes .�..�on:. <br /> Legal Desc'iplion Tax Lot Acreage or Lot Size <br /> /DO 4C, . . <br /> Subdivision Name Lot • Block - <br /> Property Address City State Zip Code • <br /> Directions to Property: 17621 Age £u� R. 3 NE 'I IocarD~ p2 - 1 ? 347 <br /> .. . . L. : — Facihty L propgd Facility/-WaterInforniation • .__ <br /> - _. ............._ <br /> a <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ®Single Family Residence ] Single Family Residence ❑Public <br /> 3 • 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private Li C•A 1 <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> - APP -. <br /> .s <br /> ❑ Site Evaluation ❑ Renewal Permit DAnthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . J 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 /> c\ca2 1Z. ?vi.It 1A6 s 03 $73 $i17S - <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO 81) • 1-573 - 5l l u ta.NV-b e-► .02 q73 g i • - <br /> Applic is M ' . Address <br /> Sign e Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />