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Application for Onsite For City Use Only: D•teSoma: <br /> Wastewater Treatment System City of <br /> Dateal <br /> Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt k <br /> xww.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <br /> j3rnl72.. Jdiot/sm 31/a( 136.-lrrh,44ck45 Sat , ow_ 4-nt2 5;5-591-%St_ <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> **es 5643,- __ L e-a• <br /> Legal Description Tax Lot- Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 3/(0( Set L1y,t+ync w .LS Selig.-,1 O2 Cr730z <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 /> Name <br /> Number Bedrooms Number of Bedrooms KI Private LANA/ <br /> 0 (Wier - 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 9 Renewal Permit ❑Authorization Notice for: <br /> 9 Construction Permit ❑ Permit Reinstatement 9 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 9 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 9 Existing System Evaluation ❑ Personal Hardship <br /> gj Alteration Permit ❑ Record Review 9 Temporary Housing <br /> ❑ Major lR] Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 9 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 famished 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 /> Se,... .- V /Min"... La_ SO3 -.8—' 711-qt!(C/ 3Esge, <br /> App cant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.it (if applicable) <br /> Pa go,c i22z st itx,->U., (IC ern*" <br /> Applicant's ad� I � <br /> C0 -/-1 Aai4g"'3 <br /> Sign , e Date: CCB# (if applicable) <br /> Applicant is the 9 Owner Y'Authorized Representative f-y Authorization to Apply form Attached <br />