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Application for Onsite <br /> ,,,i ;a,,„z. For City Use Only: Date Stamp: <br /> =- Wastewater Treatment System city of <br /> Date Received <br /> MEM 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# <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> A Property Owner Information <br /> (tkk6 ik 1 net COOrlik 7636 L . lhle Cr Ic. qd Se & em 9730 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B`Legal Property Descnption <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name 6SI I)filkakory C-04At) Lot Block <br /> 76 `1C Scitfie Cpc.ek gd. SS Scelev✓1 0a. dI7Z j? <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water-Information; <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 1710 ' idefte 0 J1 Single Family Residence OPublic <br /> 6 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ElRenewal Permit ❑Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ❑ Minor El Existing System Evaluation El Personal Hardship <br /> El Alteration Permit El Record Review ❑ Temporary Housing <br /> El Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> , <br /> kociettn 8.viI amiA (AM)88L-I 63,96 3(319 j <br /> Applit's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO. >3CX 6-20 Lyo'. g73i8 <br /> Applicant's Mailing Address <br /> 06 -0U- OQaI a19731 <br /> igna a Date: CCB# (if applicable) <br /> Applicant is the❑Owner ®Authorized Representative ]Authorization to Apply form Attached <br />