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if <br /> Application for Onsite <br /> pp For City Use Only: Date Stamp: <br /> ��� Wastewater Treatment System City of_ ® C�E Q V <br /> ni. p� <br /> D <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by ppp <br /> BUILDING INSPECTION DIVISION Zoning by JAN 162019 <br /> CC7 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> LI <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# _ �j y/ <br /> A.Property Owner Information <br /> tG-}-46Ac- V406 ktAr 27 Hoz I..,\)e,r2-J‘\ S- Pad 04- f713 5t,3-17-Geti 7 <br /> Name <br /> 3_17-G4ti- <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ( kik 66 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Named Lot Block <br /> 2 Z L-{,oZ \2—`\J Cr 2� NIri 51- . ec'Cw Oa- Gt 7 i 3 <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 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 1 ' Private U./el/ <br /> ❑ Other �' Other 9.91e barn FX itroo' NGdu`t Well, Spring,Shared <br /> D.Type of Application 0 <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> F 1 Alteration Permit El Record Review El Temporary Housing <br /> El Major f Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) ' ` <br /> CA Other—Please Specify ---` ( V\.e l 4`' <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 /> ?ClAY G Uv,066 503— 847 - 1(1?- <br /> . , <br /> Applicant's Name—Please Print Legibly Applicant's Phone NumberDEQ Lic.# (if applicable) <br /> '27`.(7 2 2�/ )2,uev- N --- 5 f onnoAA, 6 i`- 4-7/3 7 <br /> Applica 's Mailing Address <br /> l'i/k - /— /P <br /> /7 <br /> Si ature Date: CCB# (if applicable) <br /> Applicant is theOwner Authorized Representative <br /> El Authorization to Apply form Attached <br />