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• <br /> • <br /> • <br /> Application for Onsite <br /> 2'� For City Use Only: Date Stamp: <br /> - Wastewater Treatment System cit of <br /> • <br /> Date Received <br /> 11111 MARION COUNTY PUBLIC WORKS • Received by <br /> _BUILDING INSPECTION DIVISION Zoning by <br /> • 5155 Silverton Rd NE Fee <br /> • <br /> . - . Salem OR 97305 <br /> (503)588-5147Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us(PWBuildingInspection Activity# <br /> ,+ • <br /> A Property Owner Information • • <br /> • <br /> ir4ji lary \41�( iv, to 1'13 -5t imaNsitiA,r SI/V4/45".i oI.(::r7 L/ (P3)930-751..5 <br /> Name Mailing Address City,State,and Zip •(Area Code)Phone# <br /> • B.Legal Property Description • . . <br /> • <br /> • S o0 7 ru/-o 44 • - .1,4W S Ar.2 - <br /> Legal Description • Tax Lot Acreage or Lot Size ' <br /> Subdivision Name Lot Block <br /> 10 t'•3 :. ft•d'NC. . 61 liAze OIL— q-239/ <br /> Property Address City State Zip Code <br /> Directions to Property: /,Z A%105 N,QF oe4aritAf,IOWbu, Gla 4,1_,,t!$xnr' <br /> • C.Existing Facility/Proposed Facility/.Water Information • . <br /> • <br /> Existing Facility: ' Proposed Facility: Water Supply: <br /> El Single Family Residence ❑ Sin&e Family Residence ❑Public <br /> - . Name <br /> Number of Bedrooms Number ofBedrooms ❑ Private - <br /> ❑.Other ❑ Other • Well, Spring,Shared •. <br /> D.Type of Application' <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorizatiox Notice for: <br /> ❑ Construction 16 ermit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit • 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 7 Existing System.Evaluation ❑ Personal Hardship <br /> • ❑ Alteration Permit \i Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor r Other 0 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 famished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Qn nifty,permission to enter onto the above described property for the sole purpose of this•application. <br /> 41:1 ' . (523) 930 iS15 <br /> Apphcant''s Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) . <br /> l vr{> 5(.4iN►ty► - 34,57 git AM&guy.S.c; SAtowsv4. 4973/7 <br /> 0/'3 5;/ )-Rd J 53/ -12. 1-23 s/ • • - <br /> - Applicant's Mailing Address • - . ' • <br /> • <br /> • /11LAr'/AA;Z:' /74//, ' ' <br /> Sign Date: •• . . . . CCB# (if applicable) - ' <br /> Applicant is the,Owner 10 Authorized Representative 0 Authorization to Apply form Attached • <br />