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, r(ep _ii 162y <br /> Application for Onsite ' <br /> For CityUse Only: EC Date stamp: <br /> E <br /> _._ Wastewater Treatment System City of .1U1 O r o�� <br /> 1.1111.11 MARION COUNTY PUBLIC WORKS Date Received <br /> Received by <br /> BUILDING.INSPECTION DIVISION Zoning by I JIABIC1P4 COUNTYON <br /> 5155 Silverton Rd NE BUILDING INSPECTION <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> w�v�v.co.marion.or.us/I'W/Buildin Inspectiou Activity# <br /> A.Property.Owner Information <br /> Rue tt+.tt_ F3.�..-my <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 /> .115(3 S e.f e..1ti ce4v165 Wit.aJl S e 1rse— C2 ci-730 <br /> Property Address. City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Mingle Family Residence 0 Single Family Residence ['Public <br /> a Name <br /> Number of Bedrooms Number of:Bedrooms Private 0/64, <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major Li Minor N Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major ❑ Minor ❑ Other 0 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 ,. <br /> Applicant's ddre <br /> ""eV-..lrJ•-t 3 2016.83 <br /> Si ture Date: CCB# (if applicable) <br /> Applicant is the 0 Owner lOrAuthorized Representative 'Authorization to Apply form Attached <br /> , <br />