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c . .-.._ED <br /> • Application for Onsite For City Use Only: r Date Stamp: [�� <br /> ---- :_� Wastewater Treatment System city of - m u J <br /> Date Received 6 5 CO ___2.IIIIII MARION COUNTY PUBLIC WORKS Received by ,Z fa <br /> BUILDING INSPECTION DIVISION Zoning by ..-0 00 o <br /> LO <br /> 5155 Silverton Rd NE Fee "U 0 <br /> Salem OR 97305 Z <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www co marion or us/PWBuildrnelnsnectron Activity # . TC-_- <br /> t A_Pia e Owner hiformatio► <br /> g05 s Aq i i&,C 12155 elnl vn C— VICO/az/9 la q 7 Z23 5b3 -WE - 62Z1 <br /> Name Mailing Address City, <br /> " SYre <br /> ad Z....p... ... ... (Area C <br /> od )P <br /> n # <br /> '" D rIg o ----,...-----re)-,-",,-1 .L1ft egal 'jpP , c . 5-ilii::::: <br /> TSec6E� lob �8 -. 3 2 b3%oc7 <br /> LegaDescription ` LLot � Acreage Size <br /> g' ile/er�s <br /> I k m/V7/ 3 <br /> Subdivision Name Lot Block <br /> 49" <br /> Property Address Ci State Zip Code <br /> Directions to Property: . 2 a - /1/. — r ' ,/ `_ f-,#,&J di- _,;,.÷.. c, jA& <br /> ;, ::. ::. w C•Existing Facility/PrOpo#e4 Facrli3'..,Water Tn+brmatton,:> .' �. pry, k� <br /> rs <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single FalResidence Single Family F1esidence ❑Public <br /> / Name <br /> Number of Bedrooms Number of Bedrooms ,Private R bc.f` <br /> ❑ Other ❑ Other...,,. <br /> therWell,Spring,Shared <br /> ..:..:-:n.."NVRRHFHFEsRWgNFREBNMNAR/D-T` ti bf hoatton ' r s r �'' v Utz:-c <br /> 3'Ix........gip. <br /> El Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> &Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ® Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other-Please Specify <br /> / C.� 7'•.6k Iti ..lei.bit2C4 6oft , <br /> I 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 1 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 /> Sdn sir✓'ccs, �Le, S�3--g9F-1/yyc- 3925 <br /> Ap icant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> /e2 Boo,- S/ /Ii,'/1�.7y1 0re,�� 9 :31 <br /> Applicant's Mailing Address <br /> `'i�� , CP.2-1kt>/?-a 1 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the[j Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />