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y <br /> C9I -b( L1 di <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 RivertonOR Rd NE Fee I <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt it <br /> www.co.marion.or.us/PWBuildinglnspection Activity# • <br /> A.Property Owner Information <br /> C C( N x <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> • B.Legal Prope escription <br /> Li t57) <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> asp cii M - Ilzj\.,f,s6 A C - <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 /> [ . , — ❑ Single Family Residence Public LA . 0 <br /> - h►�. I ° .• N. ii <br /> N i,er of Bedrooms Number of B drooms ❑ Private <br /> Other 4 \ NOCA AN N`' 0 Other Well, Spring,Shared <br /> D.Type of Applicatio <br /> 0 Site Evaluation ❑ Renewal Permit uthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> . rg Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 3 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other. 0 Connecting to an Existing System Never in Use <br /> VAVI I over 5-yrs old) <br /> R '��U" 1 ►dJ ther—Please Specify <br /> 4C -6 <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 /> 4he1 bitt o'3o �3 -143 d -13 3U LGi g <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Po 110( SDI —i"tArrner, O'(L ail cI <br /> lic 's Mailing Address <br /> • Z4146V <br /> gnature Date: CCB# (if applica le) <br /> Applicant is the 0 Owner N Authorized Representative 0 Authorization to Apply form Attached <br />