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[--- ...‹, <br /> 091 -60D Lid-1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> City°f <br /> no <br /> y z Wastewater Treatment System <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee EXPIRED <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildin2lnspection Activity# • <br /> (�,� A.Property Owner Information <br /> O Z'IN x <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> • B.Legal Prope escription <br /> LA t51) <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: • <br /> • <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> t El Single Family Residence Public A ►, , 0 <br /> 'AIT,�0 Imo!:• N. ,4 <br /> N .s er of Bedrooms � A� Number of B drooms El Private <br /> Igi Other u \ 'lAAnttoM' 0 Other Well,Spring,Shared <br /> D.Type of Applicatio <br /> ❑ Site Evaluation ❑ Renewal Permit authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> . tgi Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major [51 Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other. ❑ Connecting to an Existing System Never in Use <br /> 6 over 5-yrs old) <br /> 1 " 1 ritther—Please Specify <br /> f\Se45 \ ' li VC#4.04S4 . <br /> If the required fee and atta hments 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 /> E:e4-19\el E31 o 503143 a -13 3lD Ft & <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 'PO 11NX Sbt—I —tArinelr', OQ 01, Yi a <br /> • ..tic.i is Mailing Address <br /> 0 tit 155 <br /> S gnature Date: CCB# (if applicable) <br /> Applicant is the❑Owner N Authorized Representative ❑Authorization to Apply form Attached <br />