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., ,,,,` Application for Onsite For City Use Only: Date Stamp: <br /> " ; Wastewater Treatment System <br /> City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by _ <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 • <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> . .A Property Qwner Iriformat�on ` ,__~__ <br /> o .JJ«- ,2704,-&If , ,4„‘er ©,- 9736Z 603-5-c1-53%6 <br /> Name Mailing Address City, State,and Zip (Area Code Phone# <br /> B Legal Property Descnpbion <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> /5/6S 4), L mo,s.` „ m71-41Gr/ • eoZ Z <br /> Property Address City State Zip Code <br /> Directions to Property: - <br /> ;' C Exiiltty/Proposed Facility(Water Information a <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 14 Single Family Residence DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private _ <br /> ❑ Other • ❑ Other //�, Well, .pang, Shared <br /> D T e'of A lication <br /> ❑ Site Evaluation El Renewal Permit • thorization Notice for: <br /> E l Construction Permit ❑ Permit Reinstatement ig Replacing a Dwelling ` <br /> ❑ Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation El Personal Hardship <br /> El Alteration Permit El Record Review ❑ Temporary Housing <br /> El Major El Minor El Other r ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Git,d ik-e! 503- SS 9R 5'566 <br /> Applicant's Nam'e/—PleaseD/ Print LegiblyI ✓Applicant's Phone Number / DEQ <br /> gLic./# (if applicable) <br /> /V65 kL h„ - �+?O4�/°r F•J /r/ mY i1 -� �,( /73 c <br /> Applicant's Mailing Address <br /> •ignature Date: CCB# (if applicable) <br /> Applicant is the CI Owner ❑Authorized Representative El Authorization to Apply form Attached <br /> G:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />