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, Lq-Op3079-- 6./AL- <br /> A, k4,„ Application for Onsite For City Use Only: Date Stamp: <br /> --- U, �� Wastewater Treatment System City of -11111 _ <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 2 9 VW <br /> 5155 Silverton Rd NE Fee <br /> Salem OR97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# Rt1ILDING INSPECTION <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> -, --:--A Pro erty Owner lnforniation_,_- - <br /> -� �1 i I3 Ir k- 4 64 �7�2 7-74-3-CT Naie 7 <br /> Mailing Address City, State,and Zip } (Area Code)Phone# <br /> li-rsi' ''9 .--...: <br /> B Legal Properfl_y_Description--------- <br /> —=- — — <br /> --17---- <br /> s-z <br /> A4„41. <br /> Legal Description ( Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 132/3 Ara ( ASE 41A.ro re 170 : . <br /> Property Address city I State TCode <br /> Directions rope-ty: 1S dJ - �I a I ( %.d ! )� e e_— i <br /> to R tf � 11 net f- i Aj— IV 1 ate, A) S' _ ® r <br /> C Ex sting Facility/Proposed Facility/Waterinformation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence Single Family Residence ❑Public <br /> Name. I <br /> _ Number of Bedrooms Number of Bedrooms Private (d e , <br /> ❑ Other 0 Other Well, Spring, Shared <br /> { ...D Type of Application.. <br /> -IC. Site Evaluation ❑ Renewal Permit ❑, horization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . 4n '-.lacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer • The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> E 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 /> K ate. (I h� 3 -7Z - `r1�' <br /> Appli is Name-Please Pri Legibly Ap licant's Phone Number DEQ Lic.# (if applicable) <br /> 1�� 13 ,4r-r\j4- ki9E A,croi c, ak_. 1101-D--, <br /> Applicant's Mailing Address <br /> .e Ali q/i- /4/61 . <br /> Signature I Date: CCB# (if applicable) <br /> • <br /> Applicant is tie Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTICIS-01 ONSJTh APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />