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22-CO(o ?- EVA-I <br /> CO <br /> 0 <br /> ,,r. ,„m,,,, <br /> , Application for Onsite . <br /> For City tJse.Onl DDa`mg: <br /> — =.0 Wastewater Treattent System Cityity of ' <br /> Z 2V i— <br /> ll"' <br /> MARION`COUNTY'PUBLIC'WORKS Date Received <br /> Received by . . O [f lhj <br /> BUILDING INSPECTION DIVISION Zoning by C o <br /> 5155 Si�verton Rd NEB n Z N <br /> F <br /> Salem,OR 97305 (Mi <br /> (503)588-5147 Fax(503)588-7948 Receipt.#. O <br /> w Activity# Z � j <br /> ww .co marina:orms/PW/Bailding nspection <br /> A.Poperty;Owner Information <br /> tJt.-i►A& l.. NO 'lir t9S t` �10 C t.G&etr Chrel'e 5uht yw t`t! 4 ir' e 7. r S. sR . o$1: <br /> Name Mailing Address City,.State,and Zip (Area.Code)-Phone# <br /> B Legal Property Description <br /> (.w.5(rr)e t)ieu &, G -S cgzt hts-4rOn6po z.vt <br /> Legal:Description Tax Lot Acreage or Lot Size. <br /> I':1 .. . . • i.., <br /> Subdivision.Name Lot Block <br /> 5736 2 -)e'`` ,ve. S SeZ..e <br /> Property Address City 'State Zip;Code <br /> Directions to Property: PYo pt r L-V b 4-�:wt .5")'0 F4 eic g-jZ Z ?a"( ,4 v e SE <br /> Sck.Ce> ) j <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: , Proposed Facility; Water Supply:❑Singie.FamulyResidence ('Single Family Residence ❑Public <br /> 2 Name <br /> Number:of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other *ell,Spring,Shared , <br /> D:<Type ofApplication ' <br /> Site Evaluation ❑ Renewal Permit <br /> ❑Authorizaon Notice for.. <br /> ❑ Construction Permit 0 PeuutReinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One`or More Bedrooms <br /> ❑ Major ❑. Minor 0 Existing System Evaluation 0 Personal Hardship <br /> El Alteration Permit ❑ Record Review ❑' Temporary Housing. <br /> ❑ Major ❑ Minor 0 Other ❑. Connectin to an Eisting,Sy stemNeverinUse <br /> (over 5 yrs old) <br /> 0 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 atthe entrance to the property. Flag.the::test holes. <br /> By my signature,T certify that the information.Ihave 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 /> 1)r ( e✓ S-b3 9 4 /53L . gcg <br /> Applicants Name—Please:Print t Legibly Applicants Phone Number DEQ Lie.# (if applicable) <br /> PC3 ') I <br /> x- 2.1t z' Y 97 2,7 <br /> Applicant's Mailing.Address <br /> i z z... 7 <br /> Si i a)--C67--- <br /> ttire. 'Date: CCB# (if applicable) <br /> Applicantis the 0 Owner ❑AuthorizedRepresentative 0 Authorization to Applyform.Attached <br />