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`°�,.,„,, Application for Onsite <br /> For City Use Only: • Date Stamp: <br /> - •�%: 1, Wastewater Treatment System. City of <br /> mu • <br /> •Date Received <br /> ,MARION COUNTY PUBLIC WORKS ' Received by <br /> BUILDING INSPECTION DIVISION Zoning by . <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fcc <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.titatiOn.or.iiS/PW/Buildinditspection Activity# <br /> A.Property Owner Information <br /> '✓e Lis e( Z313 er wins <br /> Nam p 5 Yle I.�ZiZer. Or C�7 363 Sod- 73U - S l�tS <br /> Mailing Address City,State;and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal DescriptionTax Lot <br /> Acreage or Lot-Size <br /> Subdivision Name Lot <br /> Block <br /> 310 g oul ber r At DE i ( Or <br /> Property Address City ac't o L(Z <br /> Directions to-Property: State Zip Code <br /> C.Existing Facility/'Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: <br /> Water Supply: <br /> ['Single.Fatuity Residence ]'Single Family Residence <br /> ❑Public <br /> Number of Bedrooms Name <br /> Number of Bedrooms <br /> ❑ Other ❑ Private <br /> ❑ Other ' Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site'Evaluation ❑ Renewal Permit <br /> ❑ Construction Permit El Notice for: <br /> ❑ Permit Reinstatement Er Replacing'a.Dwelling <br /> 0 Repair Permit ❑ Permit Transfer <br /> [� Major ID :Minor ElThe Addition Of One or More Bedrooms <br /> ❑ ,Existing System Evaluation ,0.Personal Hardshi❑ Alteration Permitp <br /> ❑ Major ❑ ::Record Review ❑, Temporary Housing <br /> ❑ Minor ❑ Other <br /> 0 'Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> If the i•eyuired fee and altachntents are not included with this application it will be r•etwnned 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 herebygrantMariott: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 /> �t-e ' �yef . . SO 9 i <br /> el, ,3L/ <br /> Applicant's Name—Please Print Legibly Applicant's Phone-Number S <br /> DEQ Lic.# (if applicable) <br /> 0 -cN Zi ( S /<eic e — nit 97367 <br /> Applicant's M <br /> ailing Address 7 � <br /> y�- <br /> Signature gf 23.ZozZ 6 <br /> Date: / <br /> CCB# (if applicable) <br /> P ) <br /> Applicant is the.(]Owner <br /> ❑Authorized Representative 0 Authorization to Apply form Attached <br />