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® ee - 96122, ‘0,401 <br /> Application for Onsite <br /> pp For City Use Only: Date Stamp:�� <br /> �� - Wastewater Treatment System City of 0 <br /> Date Received Ta <br /> 1111111 • MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee ®2. 0 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# e'j <br /> www.co.marion.or.us/PW/BuildingInspection <br /> Activity# <br /> - z <br /> _ A.Property Owner,Information -7 <br /> 45,,Honi &011r10,-) 3‘o CCei4%^ .I .4,e_ Gjes a4 V3Y* 5-03-9tO -6Y i <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> =- B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: £�y leer Z? %; C'R%�,L,/..ve i"�ryt7 01 <br /> C.Existmg Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> El Single Family Residence 14 Single Family Residence RPublic <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> _..._ � - <br /> D.Type of Application <br /> DRI Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> O Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> l] Re a it Permit 0 P• ermit Transfer El The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ E• xisting System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 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 /> . Al G- .1-4/1-lio9—fr?Z. 4?-1-73g. 3 30 <br /> Applicant's N Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> AD Sox C30 LeLiiwi. 04 ?73- 5 <br /> Applicant's Mailing Address <br /> j2 it zow ac10Y/ <br /> 4-/ur "---------- <br /> Date:if CCB# (if applicable) <br /> Applicant is the❑Owner .®Authorized Representative ❑Authorization to Apply form Attached <br />