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09D'bb BIgS <br /> ti Application for Onsite <br /> For City Use holy: 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 Fce <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <br /> ti . l'144.SSPA,- crkig Sit Et.5 l �c�Etz dive_ 4'73 <br /> Name Mailing Address City,Stare,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 /> GALrA/ Fet,t15 Hrt7 _kW/R/1 lit 01?., <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 /> Single Family Residence ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ® Private tApeit <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 14 Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> iMajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> El 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 /> 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 Ma' " ress <br /> ' 201683 <br /> Sig at Date: CCB# (if applicable) <br /> Applicant is the❑Owner ®Authorized Representative ©Authorization to Apply form Attached <br />