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Date Stamp: <br /> Application for Onsite For City Use Only: <br /> • Wastewater Treatment City of <br /> Date Received ® U (� <br /> No System Received by <br /> in Ll (S <br /> Zoning by 4 <br /> Marion County Public Works Fee �� ® 2�,9 <br /> Phone: (503)588-5147 Building Inspection Division �i�+frt1Q� CO(J <br /> ( } 555 NE Court St., Receipt# �� <br /> Fax: 503 588-7948Ste.2260 •�.61LDJNG INSPECTION! <br /> www.co.marion.or.us PO Box 14500 <br /> Salem,OR 97309-5036 Activity# <br /> A. Property Owner Information <br /> Name Mailing Address Phone Number • <br /> Q. Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size . <br /> Subdivision Name • Lot\ Block A <br /> Property Address: O\ VACS VI' %'V,.. jk 0l� C C 2jf <br /> 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 /> ® Single Family Residence 0 Single Family Residence ❑ Public <br /> Name 'S <br /> Number o Bedrooms Number of Bedrooms 11 Private (id id <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D. Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑ Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> fS Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> la Major 0 Minor El Existing System Evaluation 0 TeHardship <br /> ❑ Alteration Permit ❑ Temonporary Housing <br /> ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> 0 Major 0 Minor ❑ 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 /> By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> a4rtmentof Environmental Quality permission to enter onto the above described property for the sole purpose of this application. <br /> D <br /> Signature Date <br /> ri0)\(\e_J\ 4Cl )OAR% <br /> App icanYs,Name—Please Print gtbly Applicant's Phone Number Applicant's E-mail Address <br /> Applicant's Mailing Address <br /> Applicant is the ❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br /> s-01 3/05 <br />