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W 0 <br /> Application for Onsite <br /> PP For City Use Only: 0 Stamp: <br /> -= G Wastewater Treatment System City of z 22 = <br /> Date Received 0 o = <br /> Z N Ind <br /> MARION COUNTY PUBLIC WORKS Received by C3 ap <br /> BUILDING INSPECTION DIVISION 1 Zoning by m CDO <br /> 5155 Silverton Rd NEZ <br /> Fee C7 ci=, <br /> Salem OR 97305 = <br /> (503)588-5147 Fax(503)588-7948 Receipt# p <br /> www.co.marion.or.us/PWBuildingInspection Activity# Z Q <br /> �"� ( "767544_ _ A Property Owner Information m_ , `j _ _ u , .... <br /> K v��► Aax`t e t•°d fer IlLS� u 'a��f a� -`I -p`lc/S'3 <br /> Name Ft c.) c] wS dt.Mailing Address City,State,ana Zip (Area Code)Phone# <br /> B..Legal Pro ertye scnptton r <br /> 66 WAc.__Fa. _u a) o 7"0( <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 7s 7 ' Mt A ( 5;(ti 4-Ovt, e":-.:1ç' Q 8Property Address ! City r te Zip Code <br /> Directions to Property: <br /> F _ ._ CExisting Facility!Proposed Facility/WaterInformation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single Family Residence i''+Single Family Residence :Public <br /> Name <br /> Number of Bedrooms Number Bedrooms [Private tAla I <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation El Renewal Permit Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation Personal Hardship <br /> ❑ Alteration Permit El Record Review 0 Temporary Housing <br /> El Major El Minor ❑ Other El 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 /> e_coS ,/V1fAxi 7)i (c-3 g--6 3 Zodol <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /670 / cf S� til-e- - ak1. G °� `2 <br /> Applicant's Mailing Address <br /> NV(/' All/(/6"1- . <br /> 6//v/9 <br /> / 7.ci.c,e <br /> Signature Date• CCB# (if applicable) <br /> Applicant is the El Owner El Authorized Representative 'Authorization to Apply form Attached <br />