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2/-07 2/li - /� O <br /> .n, kau,,. k $ i D Ons ite For City Use Only: Date$ yp:JaiZ V <br /> ��`1�\ City of e� a.. <br /> W <br /> Wastewater Treatment System 0 4 <br /> Date Received t_—' <br /> co 0 <br /> Mil rill o ri <br /> MARION COUNTY PUBLIC WORKS Received by *' <br /> BUILDING INSPECTION DIVISION Zoning by �? Q : ,e,.. <br /> 5155 Silverton Rd NE Fee r 5 <br /> Salem OR 97305 J <br /> (503)588-5147 Fax(503)588-7948 Receipt <br /> ty# Pi__ j <br /> ActiviO3 <br /> www.co.marion.or.us/PW/BuildineInspection <br /> A.Property Owner Information <br /> Name y 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 /> a/AY\IIoa. V e .. a(L. On.5.a <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> DSingle Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> O Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> igi Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major IN Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> E Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> -1-0v\1— \U 'c% . ❑ 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 pplicant's Phone Number DEQ Lic.# (if applicable) <br /> Ap lic •Ii ig A s <br /> L \ ) al LIu5S-1 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner [,Authorized Representative ❑Authorization to Apply form Attached <br />