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Application for Onsite <br /> / -00(0171 -PP,r r <br /> ppFor City Use Only: Date Stamp: <br /> =-3 City of Wastewater Treatment System '.) 1. <br /> Date Received ■� © il �/M <br /> IE <br /> MARION COUNTY PUBLIC WORKS Received by <br /> II <br /> 1 <br /> BUILDING INSPECTION DIVISION Zoning by L AUG 10 2J16 <br /> 5155 Silverton Rd NE Fee Ill$aCOUNTY <br /> Salem OR 97305 �.A -1I O N <br /> (503)588-5147 Fax(503)588-7948 Receipt# 3�. ILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> Ron it i+3 5a)4nh OR, 973/7 503 7y3-3/TN <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Legal Property Description <br /> 7D51 <br /> LegalDescription Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> r d <br /> Ip© c e S1��m E 5e►l�r� -$- 47 3 r7 <br /> Property Address City State Zip Code <br /> Directions to Property: $erfOr\ orq. \\ RA. <br /> C.Existing Facility/Proposed Facility/-Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single F.I.'. Residence ❑ Single Family Residence ❑Public <br /> rr Name <br /> Num Mr Bedrooms Number of Bedrooms 4 Private W Q\\ <br /> 0 Other 0 Other Well,Spring,Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 0 Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> cg Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 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 /> di f h1t� 503-55n- 14 Z 3 396--83 <br /> Applid�nt's Na n —P ease Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> £0005 evospn \iY\ M. `bier-l clan OR ' 737 <br /> Applicant's Mailing Address <br /> Signa.�r� `� 1 Date: ^/ CCB�if applicable) <br /> Applicant is the❑Owner 2 Authorized Representative IV Authorization to Apply form Attached <br />