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Application for Onsite ForciryUseOHIy: Date Stamp: <br /> Wastewater Treatment System Citynf <br /> Date Received <br /> ellMARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt k <br /> (503)588-5147 Fax(503)588-7948 Activity# <br /> www.co.marion.or.us/PW/Buildinelnspection <br /> A.Property Owner Information <br /> \ 0 n Qo� dd �a�o <br /> batt �IhmZip . - _�� 3 <br /> Name Mailing Address ity,State,and Zip (Area Cade)Phone# <br /> B.Legal Propaty Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name r Lot ,..I Block <br /> Prop rty Addres jA �o �uy rj r 1U` �,�� tate 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 ❑ Single Family Residence ['Public <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <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 ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> x� ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> lu Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ft 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 he 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 /> a so% aILA a sal <br /> CV �3 nu�a3 t' <br /> Applicant's Name -Please Print Le � Applicant's Phone Number DEQ Lie.# (if applicable) <br /> ' PoS is 51:5-1 il1A.�$3ec Tt a Wit? <br /> Aypljcant's Mailing Ad ss <br /> 1111111 JJ\\/� iAJ tl,a11L.II Lig sS I <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative 0 Authorization to Apply form Attached <br />