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aL -COO 4b1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> =- N Wastewater Treatment System City of <br /> 1111111 <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 <br /> r. Fax(503)uil588-7948 Receipt# EXPIRED <br /> www.co.marion.or.us/PWBuildingInsnection Activity# <br /> A.Property Owner Information <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 /> 1 to rat' St e., 1-'t <br /> Property Address Cite State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Sup <br /> ❑Single Family Residence 0 Single Family Residence NOPublic <br /> 3 Nam <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Re air Permit III Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor II] System Evaluation El Personal Hardship <br /> El teration 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. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Ap 'can 's Mailin Address ( [ <br /> q56\ <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 111 Authorized Representative ❑Authorization to Apply form Attached <br />