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Application for Onsite D F �' <br /> ,,,�, pp Far City Use Only: <br /> we <br /> Ci of <br /> ,-....---,,-,... Wastewater Treatment System ty <br /> Date Received 0 T !812\i„lEill, <br /> 1111111 MARION COUNTY PUBLIC WORKS Received by MARI'0 N -, � � <br /> BUILDING INSPECTION DIVISION Zoning by BUILDI INs° TlY <br /> 5155 Silverton Rd NE QN <br /> Fee <br /> Salem OR 97305 -\ <br /> 0/cp , <br /> (503)588-5147 Fax(503)588-7948 Receipt# ' <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# - <br /> _.____ . .—__. ' ._.__... A Property Owner Information'„ , __ <br /> 1lc cle.,\ We,- 1. ' 6er3ett/ 4 £c(c) u1R- c173/7 702 6zc ?re <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# • <br /> __ B Legal Property Description..:;_.__;�_.__ _. �a ._____� _.__.__; __._..;_ � _..__. .. ._._._._.a..j <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 31613' 86511 ,1 P( f'C S f e M a- 7 73(7 <br /> Property Address /� Cityl/ State Zip Code <br /> Directions to Property: 0 el a 'I L J �� &4I/e. el�J t_ G / �e j0?a/' <br /> C Existing Facility/Proposed Facility/Water Information, <br /> Existing Facility: Proposed Facility: Water Supply: <br /> i <br /> (dSingle Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms g Private W I <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D Type of Application_ . m JM <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 4'Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 2'Major ❑ Minor ❑ 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.(111‘Cl\qe. 1 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3({ 1c 6cr,5..Mgv, Pl. S __ sGrem <br /> Ap licant's Mailing Address <br /> 10 70e/20 2 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />