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CO <br /> Application for Onsite <br /> For City Use Only: e -111 <br /> ----— ; Wastewater Treatment System City of - c <br /> Date Received C)_0 l— <br /> NM Ii�IARION COUNTY PUBLIC WORKS Received by z- ' O I na <br /> BUILDING INSPECTION DIVISION Zoning by 0 <br /> 5155 Silverton Rd NE Fee Ill 2 <br /> Salem OR 97305 0 Z <br /> (503)588-5147 Fax(503)588-7948 Receipt <br /> # H� L� u <br /> Awww.co.marion.or.us/PW/Buiidinglnspection r---3 <br /> A.Property Owner.Information <br /> R.o\1.. 40 174=77t:.is St S'etI Or 5 3 '5 5.e,a -3,0®2D7t) <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description: <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 9 C S ,//L 1r ou4ns7d c t r 1 l, ,�c e)Paz-- S -7. - <br /> Property Address Cit State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Ingle Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> 0 Other ❑ Other Well,Spring,Shared <br /> D.Type of Application[]'Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> ❑ Constru 'on Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Flip ' Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> - ❑ Major ❑ Minor 0 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 /> i) a.LSa-&._ - 8-7,5-7/..S7 ,I'7e o� <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> '2'7 eC'--- ee4,5c-azi-z 117 /1,,Z- _ei I(---"r--, ‘A-- Or 3 7-1k-) <br /> Applicant's Mailing Address <br /> f'gn c �J b I r'1aL <br /> i ature Date: CCB# (if applicable) <br /> Applicant is the❑Owner (i Authorized Representative El Authorization to Apply form Attached <br />