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Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> 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# <br /> www.co.marion.or.us/PW/Baildinglnspection Activity# <br /> ._ A ProPerty Owner Information <br /> groom 3 q36 �Cie ce,O a ,�'� Ievn 7 I7 3-0 —. 'e>8- el?4. <br /> Name Mailing AddressB City,State andZ (Area Code) <br /> PropyDescrPhon Phone# <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: <br /> . <br /> sting Facility(Proposed Facility%Water'Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence f�+ Single Family Residence %PPublic C.a It <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D Type of Application _ <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> j Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> [r Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 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 /> Bethel Excavating 503-743-2343 36198 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 504 Turner, OR 97392 <br /> Applicant's Mailing Address <br /> VA a l 6 /20-3 44551 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner © Authorized Representative ❑Authorization to Apply form Attached <br /> 2 <br />