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a bps _6-0714 <br /> v , Application for Onsite For City Use Only: I 11 <br /> 0 r--' r",-,t, _ _ \te <br /> Wastewater Treatment System City of- <br /> r Date Received fel APR 0 5 2021 -) <br /> MARION COUNTY PUBLIC WORKS: Received by <br /> BUILDING INSPECTION_DIVISION— Zoning by <br /> 5155 Silverton Rd NE MARION COUNTY <br /> Salem OR 97305 Fee BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildineInsnection Activity# <br /> KA.Property Owner Information <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> .5i// (7J/ 0ot— <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name // Gay' <br /> '' Lot Block <br /> Property Address I 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 II Single Family Residence ['Public <br /> 3 aName <br /> Number of Bedrooms Number of Bedrooms Private /:),/,H /0 <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement KReplacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer The Addition of One or More Bedrooms <br /> ❑ Major _❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />