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Application for Onsite For City Use Only: Date Stamp: <br /> ; r <br /> . ,:. City of <br /> Wastewater Treatment System pL!CE� v <br /> �IE <br /> �- MARION COUNTY PUBLIC WORKS Date ReceivedReceived by — II Ap',� v <br /> BUILDING INSPECTION DIVISION Zoning by l ,'6 2019 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> A Pro e Ov�hterInformation <br /> I -73 rt - <br /> ?ial"r%Ciu HC (l S` L I I ouc,1e 1)r NZ 6v) verrsic+i DYE q73 -j AOS' yo-vp <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Legal Propeescrtptzon" <br /> olueS , � I" <br /> • Ces A.0g�. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 13 0 IC t�cwtoes a P ek n--fit 1t s <br /> Subdivision Name Lot Block <br /> • <br /> 59 IP 1 TOuY1e Or Aie- ;►ittI.e Ow i 9-73S'/ <br /> Property Address City ( State Zip Code <br /> Directions to Property: <br /> "3,-„ y CaExisttng,Facility f Proposed Facttty(Water Information.i'. ;F, ,, i3 _., ,'U <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence B1 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms I Private <br /> ' <br /> O Other ❑ Other Well pring,Shared <br /> r DT eoA liatn <br /> O Site Evaluation ❑ Renewal Permit XAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement EReplacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ 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 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />