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P , _____ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> City of <br /> %�`� " Wastewater Treatment Date Received <br /> IIIIIII System Received by <br /> Zoning by <br /> Marion County Public Works Fee <br /> Phone: (503)588-5147 :Building Inspection Division <br /> Fax: (503)588-7948. <br /> 555 NE Court St.,Ste.2260 Receipt# <br /> www.co.marion.or.us: PO Box 14500 <br /> Salem,OR 97309-5036 Activity# <br /> A. Property Owner Information <br /> Llo . d ellkI 8R3g 3lve(Vo,l1S I-1-v_Ny � AurrvldJ O350c1 -2h7 <br /> Name J Mailing Address P one Number <br /> B. Legal Property Description <br /> O8 ) 13C o2s oO 6.50 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name , Lot Block <br /> Property Address: se 8 Ji11113 1j` y s _ Aue-nvi' ll e Jt` <br /> x325_ <br /> Address City' State Zip <br /> e <br /> . <br /> Directions to Property: <br /> C. Existing Facility/Proposed Facility/ Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 54 Single Family Residence ❑ Single Family Residence ❑ Public <br /> +11i-Ce <br /> n .t - Name 11 <br /> Number of Bedrooms Number of Bedrooms 11 Private Lac( <br /> ❑ Other <br /> 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 /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Personal Hardship <br /> O Major j Minor -❑ Existing System Evaluation 0 Temporary Housing <br /> ❑ Alteration Permit ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major 0 Minor ❑ Other ❑.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 Environmen 1 Qual' permission to enter onto the above described property for the sole purpose of this application- <br /> 51 (2019 <br /> Signat Date <br /> "j' e-e -it its - 503 3C2- 7000 �rnri`eo76r)I, W-W ) <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number Applicant's E-mail Address <br /> -PO • Bo-x 5x41 Sa1tvo, 01 87304 <br /> Applicant's Mailing Address <br /> Applicant is the ❑Owner [Authorized Representative KAuthorization to Apply form Attached <br /> S-01 3/05 <br />