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1 <br /> Date Stamp: Viv.Dc ) <br /> ., Application for Onsite For City Use Only: FrirCIE <br /> n n t7 ^�Wastewater Treatmentcity ofDate Received , J <br /> mg <br /> System Received by FEB 13 2019 <br /> Zoning by IVIAkiON COUNTY <br /> Marion County Public Works <br /> BuildingInspection Division Fee 3UILDING INSPECTION <br /> Phone: (503)588-5147 P <br /> Fax: (503)588-7948 555 NE Court St., Ste. 2260 Receipt# <br /> www.co.marion.or.us PO Box 14500 <br /> Salem,OR 97309-5036 Activity# <br /> A. Pro erty OMner Information <br /> ' iC• , ( <br /> n <br /> ame Mailing Address Phone Number <br /> 13. Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address:_:_cc ^C`�� 11 � r0,_.\1..)a, J <br /> Address Sty State Zip Code <br /> Directions to Property: <br /> C. Existing Facility/Proposed Facility/ Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> XI Single Family Residence ❑ Single Family Residence ❑ Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D. Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑ Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ® Repair Permit Ay,,4_0\u, ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major Jki Minor , ❑ Existing System Evaluation 0 TemporaryPeonHardship <br /> ❑ Alteration Permit ❑ Housing <br /> ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> 0 Major 0 Minor El Other <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 /> Bxmy signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Depxartm f Environmental Quality permission to enter onto the above described property for the sole purpose of this application. <br /> Signature Date <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number Applicant's E-mail Address <br /> Applicant's Mailing Address <br /> Applicant is the ❑Owner Authorized Representative ❑Authorization to Apply form Attached <br /> S-01 3/05 <br />