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Application for Onsite <br /> For Clty Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Ii' Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt iF <br /> www.co.marion.or.us/PW/Buildivanspection Activity# <br /> A.Property Owner Information <br /> e 616 bier- 782 36'$arakLk,S Sale wt t(fig ql 3Oce 50 -•qyc S—igi <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description f <br /> 10 -5 W 0Z 3l L24'O <br /> Legal Description Taj. bts Acreage or Lot Size <br /> kW <br /> Subdivision Name Lo12.6Agi Block <br /> Property Address City State Zip Code <br /> Directions to Property: J tAl 5t e. i7P P-j Per2 12� °'I"° <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence i( ,Single Family Residence ❑Public <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms g Private <br /> ❑ Other 0 Other Weli�Spring,Shared <br /> D.Type of Application <br /> 4 . <br /> Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> Construction Permit 0 Permit Reinstatement <br /> ❑ Replacing a Dwelling <br /> ❑ Repair Permit <br /> ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review <br /> ❑ Major ❑ Minor ❑ Other ❑ Temporary Housing <br /> ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> If the required fee and attachntents 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 /> &kit- C7oba1- 6-03--cluq-6-ici I <br /> Applicant's Name Please Print Legibly Applicant's Phone Number DEQ Lie.it (if applicable) <br /> 7 3arcth L1. 5• Safeh'1 OR q.)3 o <br /> Applicant's Mailin Address <br /> 1 j! 9 146,Z z <br /> i nature Date: CCB# (if applicable) <br /> Applicant is theOwnet ❑Authorized Representative ❑Authorization to Apply form Attached <br />