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EXPIRED <br /> Application for Onsite <br /> PP For City Use Only: Date Strmpt <br /> im- ` _ Wastewater Treatment System City of ii.” , Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Riverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.mari91419540/PW/Buildinglopection Activity# <br /> A.Property Owner Information <br /> MA-c'' P. (A...).. is 6-215 `c7t-a i_ou;S R,, C.1<q-ve.,2es , OR g10Z.(.. (50'3)S-(0-Lf 2 e, <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description . <br /> 05- 2,,1.v'tO eO'O() . 20 447 e.t_ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 5-261s -. 1.41kiS ig.d N� 6CY c,lS c Z ` 10Ztfl <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 4.Single Family Residence OPublic <br /> 5 Name <br /> Number of Bedrooms Number of Bedrooms 1g1 Private W-t t <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 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 /> 0 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 /> ?)(*k-C--e- p, t ) <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Applicant's Mailing Address ` <br /> S ' '`"""1- 1-- 2.-/Iti-ZO <br /> aS �� Date: <br /> � CCB# (if applicable) <br /> Applicant is the Owner El Authorized Representative 0 Authorization to Apply form Attached <br />