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aa- bo 8.\ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> .am_ . <br /> Wastewater Treatment System 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 /> vw.co.marion..or.us/PW/Bu ldind nspection Activity <br /> s4 <br /> A.Property Owner Information <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 0(/4,S3 pc a(a C it coo 2,GG xis <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address tjJeta AcQr1ve45 City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed.Facility: Water Supply: <br /> 0 Single Family Residence ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of.Bedrooms Et Private lAkti <br /> ®' Other C.C1rtl M a,etu 1 ® Other CU+^'«" ax( Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation ❑ Personal.Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El Major ❑ Minor D Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> rt it p anV C3t6�l) f - �:T4si, <br /> s <br /> If the required fee and attachments are not included with this app 1 • . •• •, .,..' . neomplete. <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 /> Deparrtment of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282.Silverton,OR 97381 <br /> Applicant's 'lin <br /> ei— -2 2-- 20.1683 <br /> Si tore ‘---- Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ' Authorized Representative ''Authorization to Apply form Attached <br />