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Application for OnFar City Use oaly _ his u v <br /> Cityof <br /> Wastewater Treatment System Date Received D C <br /> IIIIIIIMARIDN CONNTY PUONID WORKS <br /> • Received by ] <br /> JEC 03 2019 �•(7 <br /> BUILDING INSPECTIONd DIVISION FO°'ng by BUILDING MARION <br /> COLINTY <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# �� ��� <br /> (503)588-5147 Fax(503)588-7948 Activity# <br /> www.co.marion.or.us/PWBuildingInsnection <br /> A.Property Owner Information <br /> 1. 1 , x-•5.1 R M S 1e,.- OK 973/7 Soj Sg1�OVyl. .... ... <br /> at, azo A'�•- �' Area Code)Phone# <br /> a^`� ----�— City, State,and Zip . (Area <br /> Name Mailing Address <br /> - H LegalP;operY/Description _ _... / 3 ----- <br /> Legal Description <br /> Tax Lot Acreage or Lot Size <br /> Subdivision Name <br /> Lot Block <br /> C c, �j <br /> a 70 Co,aa� RA. pc- Jf"It State Zip Code V3 / 7 <br /> Property Address City <br /> Directions to Property: ' <br /> C.Existing Facility/Proposed Facility/Water Information • <br /> _.._ <br /> Proposed Facility: Water Supply: <br /> 0Si gnglg Facility: <br /> Family Residence <br /> 0 Single Family Residence Name <br /> Number of Bedrooms Number of Bedrooms <br /> jg Private.Z OeIf3 <br /> et . m Other 3p CM'IrtcC1 Well,Spring,Shared <br /> D.Type <br /> Other r� . - .. eofA licabon <br /> PP .,. . . <br /> ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction <br /> on Evaluation Replacing a Dwelling <br /> ❑ Repair Permit Permit ❑ Permit Reinstatement - 0 The Addition of One or More Bedrooms <br /> ❑ Repair or ❑ PermitTransfer <br /> System <br /> ❑ Personal Hardship <br /> 5 Major ❑ Minor ❑ Existing System Evaluation ❑ Temporary Housing <br /> ❑ Alteration Permit ❑ Record Review <br /> ❑ Minor ❑ Othther ❑ Connecting m an Existing System Never in Use <br /> 0 Major (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 i o.e . Fla_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 /> ` So3 581 -ow-0 <br /> ._ E a u o <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (S applicable) <br /> a , .(2s,_ ' Ck. ur ;alit, oR 973)7 <br /> Applicant's ion e - <br /> ie <br /> .4 Date: /211 CCB# (if applicable) <br /> Sig . <br /> Applicant is thegOwner <br /> ❑Authorized Representative ❑Authorization to Apply form Attached <br /> GiFORMSISEPThCis-0l ONSITE APDL SEPT 2018DOCX Rev I/15,3/15 <br />