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, ; Application for Onsite R C E f V <br /> .n, ,a,,, Ph For City Use Only: P <br /> City of <br /> ---------W,-- Wastewater Treatment System <br /> Date Received AY 14 2019 C ' <br /> MARION COUNTY PUBLIC WORKS Received by MA ION C®�NTY <br /> BUILDING INSPECTION DIVISION Zoning by BUIL® G INSPEC770fv <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee <br /> (I-CAP tfc..,-/ <br /> Receipt# <br /> (503)588-5147 Fax(503)588-7948 Activity# <br /> www.co.marion.or.us/PWIBuildinduspection <br /> A.Property Owner Information <br /> 13 D <S,I) LLC, Iof5D0 UeSani-is Lh,SE, 3ifuer ®i2.9jai ,503-g73 3y?7 <br /> Name l ) Mailing Address City,State,and Zip (Area Code)Phone# <br /> t B.Legal Property Description <br /> sLega� � Sj� SLC, 2(pCO 3. 15- <br /> Legal <br /> l Dekcription' Tax Lot Acreage or Lot Size <br /> (15-eg 1°C- t,75s 144 S(1 <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: Pre erg/ ) S I oca-`-ed 04 -IP v C,rn� end D�.)e tl.n- 's Lr, . I e-(+s i/�l e. o-F <br /> road 1h �4-ke Icltoot1aI bt`K r'P OeC tMs L-n. sf) SfIvpr-i-on, _q'73R, I <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence gi Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> kESite 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 0 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 /> 0 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 /> Skerlh A. ()ecn�is 5'03-R73-3'-l97 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> l ci SOO £ e3an.-;c Lr . SE S Iv er-n, AP . 9 73R1 <br /> Applicant's Mail' • I dress <br /> aq <br /> :1 •_ /. (44/411111k 5-12 -/9 <br /> Signatur; Date: CCB# (if applicable) <br /> Applicant is the1 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />