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6 bq <br /> q <br /> U' <br /> Application for Onsite For CityUse Only: C ., <br /> ,n�} .���� �/te S <br /> r)Ag <br /> -- Wastewater Treatment System City of <br /> M <br /> Date Received -XI = <br /> 7 31=• n <br /> . MARION COUNTY PUBLIC WORKS Received by c)O <br /> BUILDING INSPECTION DIVISION Zoning by -Z ,M <br /> 5155 Silverton Rd NE (.0 0 <br /> Salem OR 97305 Fee .)0 <br /> # 11 r gi <br /> (503)588-5147 Fax(503)588-7948 Receipt0� c= <br /> www.co.marion.or.us/PWBuildin2Inspection Activity# in. <br /> A Pro Owzzer Information <br /> fgctmv\ov Line 510\ al,Sl roo LN S� 7Zw er, 9729 663,5:5P a7g/ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Le al Pro a Desch tion ; , I <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> X00 / A'// re-, 7cf` ,r,,- c,/L- 9939 L <br /> Property Address City _ State Zip Code <br /> Directions to Property _ _ _ , _ <br /> ,;RExistmg Facility/Fropased Facility I Water,Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private We D 1< <br /> ❑ Other ❑ OtherWell,Spring,.Shared <br /> _._•. Type ofµApphcation _! ' _ <br /> ❑ Site Evaluation enewal Permit tuVdk"""r ❑Authorization Notice for: <br /> ❑ Construction Permit 1=1 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ 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 /> �r(� Cs -- 503-55'x- $7/I <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> £"/vi /4a 7, ie �G�i7er, 6-1 - 9 739' ---- <br /> Applicant's Mailing Address <br /> -2 -4.34-4---).' l�5' o -c:, 0/7 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is theg Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />