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Application for Onsite For City Use Only: Date Stamp: YEE <br /> Wastewater Treatment System city°f APR 11 2019 <br /> 11111 Date Received MARION COUNTY PUBLIC WORKS Received by MARION COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by RUI_DING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww .co.marion.or.us/PW/Buildintrinsnection Activity# <br /> w <br /> A Property Ownerinfgrmatxon ___w„ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> =3 B Le al Pro a Desch tion: <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> \\V1-\ Qr6v- <br /> Property Address City State gip Code <br /> Directions to Property: <br /> C Existing Facility/"proposed Facility/'Water Infor=nati©n' :3'' j,.,3.,.,, .. _-_.. .. ..,_ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ingle Family Residence ❑ Single Family Residence ❑Public <br /> LL Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other 0 Other Well,Spring,Shared <br /> I? Type of Application <br /> El Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> AConstruction Permit ❑ Permit Reinstatement ElReplacing a Dwelling <br /> Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major or ❑ Existing System Evaluation ❑ Personal Hardship <br /> El Alteration P it El Record Review El Temporary Housing <br /> El Major ❑ Minor El 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 -_ify at the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of , vire e tal Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> _ <br /> ///4111( <br /> -S 95 /dam ��D13 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number <br /> DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />