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Application for Onsite For City Use Only: . Date Stamp: <br /> Wastewater Treatment System City of <br /> -------mi...- 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 /> www.co.marion.or.us/PWBuildinalnsuection Activity# <br /> __,_ _..A property Owner Information, <br /> LuLtA., ,17_ ((d 07 Ei#er4f� k° - 9jt 1 ©R /7 -Ill J �6 L jI7. �. <br /> _#? € <br /> e Mailing Address ,.E City, State,and Zip ea Code)Phone# <br /> _., ��,o gq(Q ;*,Legal Prope scnptior�;' I .... (Si: . toy I C: e ICU) <br /> Legal Description Tax Lot (,,,� cal Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> ki`ib? foiert& hliteiik I.K. c 617 35 2 <br /> Property Address City State Zip Code <br /> Directions to Property: Flare b9yy\ Si ' e_, ( ow.. £re-ea (,"ee r- <br /> faveir <br /> _ C Existing Facility 1 Proposed Factlrty/Water 1 formation t <br /> Existing Facility: Pro,'sed Facility: Water Supply: <br /> ❑Single Family Residence Ili Single Family Residence ❑Public <br /> 14 __/ Name <br /> Number of Bedrooms Number of Bedrooms [Private w e.t,A, <br /> ❑ Other 0 Other Well, Spring, Shared <br /> v -1 u:.. . t__,_ . ._ ._ D Type ofApplica__tion ._=._ 1 . .,_ . .h . .. .i . <br /> ❑ ite Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El 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 /> ."-cl � Y( rQ 1 v c v ( tç 4 6(4 ` (4PpA Iicant ame-Please Prit'Le 'bl licans Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> °--(111/11/1"''.------- W (V7Ii <br /> atur Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative El Authorization to Apply form Attached <br />