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.Ni ) <br /> Application for Onsite '�� . <br /> pp For City Use Only: <br /> Wastewater Treatment System City of 0> <br /> IIIIII.., Date Received i <br /> MARION COUNTY PUBLIC WORKS Received by 0 0 70 ` <br /> BUILDING INSPECTION DIVISION Zoning by 5 0C) Ifni <br /> 5155 Silverton Rd NE Fee 13 0 <br /> Salem OR 97305 Receipt# �j c i� �,n, <br /> (503)588-5147 Fax(503)588-7948 J a u <br /> w .co.marion.or.us/PW/BuildingInspection. <br /> Activity <br /> ww <br /> A Pro e Owner Information <br /> C, ndo S; � e,t'w. e,I 5V Sha.ua-NuSL l\urnsu i1� OAC 915A 5 503-Q to-L )& <br /> b L <br /> Name Mailing Address ` .City, State,and Zi Phone# <br /> ty P (Area Code <br /> B Legal Property Description _ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address ��''tt L City /�, 1 noState 2 Zip Code <br /> Directions to Property: <br /> �� �11Q Ri fl(), s Aum S\ I I v .V C)1 J of 5 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply:Single Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 14 Private <br /> 0 Other 0 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 ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship . <br /> ❑ Alteration Permit ,Record Review [1 Temporary Housing <br /> ❑ Major El Minor 1 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) . <br /> . El 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 /> Qendic Silberfla d 5 )3-9IDyBB� <br /> PP <br /> A licant's Name—Please Print lsgibly Applicant's Phone Number DEQ Lic.#_(if applicable) <br /> 58110. 416.0) Vic)(, & -Aunisu i 1 lt OR 9 73 t5 <br /> P„ <br /> A hMailing <br /> cants Address <br /> in l'Y� 3 --y -- 19 . <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the X Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />