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Application for Onsite For City Use Only: Date Stamp: <br /> CIE - 1�7 <br /> —_—� :, Wastewater Treatment SystemCity ty of <br /> �V/ ED <br /> mig, .. . . Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 10 2123 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity#_ _ BUILDING INSPECTION <br /> vvww.co.marion.or.us/PW/Buildinansnection <br /> A.Property Owner Information ' <br /> T.l' i.V\cy-6, ki-t,\Ne0 <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 /> 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 Li Single Family Residence ['Public <br /> 7 Name <br /> Number of Bedrooms Number of Bedrooms in Private _ kivel I <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 /> [S Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 4 Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> s DI <br /> av\ <br /> Major ❑ Minor 0 Other El Connecting to an Existing System Never in Use <br /> �- (over 5-yrs old) <br /> -\A\v\ VAK4e, ❑ 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 /> Depaitinent 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 /> 0 a Box 504 Turner, OR 97392 <br /> licant's Mailin Address <br /> \ • L - w ,- (-3 44551 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ©Authorized Representative ❑ Authorization to Apply form Attached <br />