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1c)\— c5 51 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ...� y Leeceived, <br /> E C E V-EWastewater Treatment S stemV <br /> MARION COUNTY PUBLIC WORKS - Received by =9 <br /> U ijMAY 1 6 <br /> BUILDING INSPECTION DIVISION Zoning by M ,,��.,, 2099 <br /> 5155 Silverton Rd NE Fee ARItUN COUNTY <br /> Salem OR 97305 • BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> --_ :, <br /> A Properly_Owner Information <br /> Ma\ ... ki'( 2,S S f.S� sae,A,,11Q73/ - X3)77(—((03 <br /> Name - Mailing Address City, State,and Zip _ (Area Code)Phone# _ _ <br /> B Legal Pro e__ I]escn tion <br /> The 17M 1t0Wilf 75z , rte- <br /> Legal Description jt- Tax Lot <br /> Uel , v-c /? 300 Acreage or Lot Size <br /> 0"7"'Pr . . <br /> Subdivision Name Lot • Block <br /> • <br /> 59.2..c,s -S� Salem-I Cil - co 3 ( 1" <br /> Property Address City State Zip Code <br /> 4 <br /> Directions to Property: ' '4..4 ,it.e.A ‘.,.1 •1- S '-- S . wi S. - - <br /> 0,..4 /1 vviixeAld (;e•P Imo.: "(.(,,o e ' I ewi(k \. Cross -- s'g v-4 av, fit& <br /> • = -- C Existui arh /Pro osed Facile /Water Information <br /> gFc <br /> ..... tY._.._..P ty . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> pingle Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms [yl Private we( 1 <br /> O Other ❑ Other Well, Spring,Shared <br /> - yP PP <br /> : D T e of A lication <br /> r <br /> 1 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> L] Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ' ./K 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 /> IAetAcre( Ss�) 77l-1(QG3 <br /> Applicant's Njme—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> S17 2 S 6 We 64-. SC SxJ444,, 0 e-1131 I- <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\SEPTICIS-01 ONSITh APPL SEPT 2018.DOCX Rev 1/15;3/18 <br />