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a1-DbD -1 9 <br /> A 1 -DY-b 1$1) 1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> -- := Wastewater Treatment System city of <br /> mg- <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/BuildingInspection Activity# <br /> A.Property Owner Information <br /> ,io 2 A,eq t,& i 7 y G0S 5 Ala, ,g, /,,,.. ��. ..-C2 9i3W sa3 '��- - tr 2.2- <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 /> ee7''f7 re...se_ /i/ �S,/1...- v (.7r 91 ,,f--( <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Prt j t sed Facility: Water Supply: <br /> OSingle Family Residence I/Single Family Residence ❑Public <br /> /t/ Name <br /> Number of Bedrooms Number of Bedrooms Private f s/e„,/,/ <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 /> Repair Permit 0 Permit Transfer ❑ 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 ❑ 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 /> 1/14€ CA-)I jsa ^ .503 lg--73 —7/5 7 3 3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ' 717 _ Ge c c41,,- 6A/ „A/' f,if, -.c 477 r f'�3-( <br /> Applicant's Mailing Address <br /> t41l.C4424'C. w4A411\11 1 'a% ' ki <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner grAuthorized Representative 0 Authorization to Apply form Attached <br />