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11 - bb53li <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City ofb---13ECE11b <br /> E D <br /> MARION COUNTY PUBLIC WORKS Received by '1 <br /> BUILDING INSPECTION DIVISION Zoning by__ <br /> CI 131017 <br /> allMARION <br /> Received <br /> 5155 Silverton Rd NE MARION Salem OR 97305 Fee COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDII\G INSPECTION <br /> www.co.marion.or.us/PW/BOild_nglnspection Activity d <br /> A.Property Owner Information <br /> 2oeii /raCS -Ler_ 8383 cl. .s744 Sf f..( U 7y35 4à -7f3 - r7?S <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> p4 Z.u.)11 Uog0O <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name n Lot pad Block <br /> 7-7133 rt...a, Pe4.t,e,;< fie• gip" cr Wir7 <br /> Property Address Cit ' r (� State Zip Code <br /> Direct�iioqp�s tp,Pro ert�yv: 2213 3 /gad- Y/La it a F.c s4 ra-t( Q <br /> Na 0( pi.! Cdr i,. - /c„t`P.,CL i2&,.te 6W/ <br /> C.Existing Facili /Proposed Facili /Water Information <br /> Existing Facility: Proposed Water Supply: <br /> ❑Single Family Residence 0 Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private Wei.( <br /> 0 Other © Other Well,Spring, Shared <br /> D. e of Appli 'on <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> jil Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ 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 /> -POEN Fg,..s Ltc 3-793 -5t-p5 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> 83 S3 no' P Sc. �aa,r Cr 971.73' <br /> Applicant's Mailing Ad ss <br /> „_l', a J""1/2 /3 ?oI7 <br /> Signa ure Date: I CCB# (if applicable) <br /> Applicant is the 0 Owner ®Authorized Representative ❑Authorization to Apply form Attached <br />