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Application for Onsite For City Use Only: Date Stamp: <br /> - : Wastewater Treatment System City of <br /> Uj 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 /> ww.co.marion.or.us/PW/Buildinglnspection Activity# <br /> w <br /> p A.Property Owner Information <br /> 14/ J tn_,e9 t t e t-7Y(a5 S Li /, vr-.,0,r- Q/.367' ._Sd3 -5sf'P'- I 24- <br /> Name Mailing Address F 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 /> d7'/7 re...is6— drO S,i- & -- _ 51,S <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Pro psed Facility: Water Supply: <br /> Single Family Residence I/Single Family Residence ['Public <br /> A/ Name <br /> Number of Bedrooms Number of Bedrooms Private 1„Atej/ <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> /r ec cJI d-COv'-- SO3--g-73 7'5 7 3 3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P-728 - GA..4 c- 4 M / �� S,4•-.cr177t L., I- 'l34..—( <br /> Applicant's Mailing Address <br /> VLA,%4ZA.1"C. tA))314-1/\11 1 %;A% - aj <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ,Authorized Representative 0 Authorization to Apply form Attached <br />