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£1 007 gcog- / JiCt <br /> Application for Onsite <br /> �,� ,;,;4,,,,,� pp For City Use Only: Date Stamp: <br /> : �". Wastewater Treatment System city of <br /> Date Received <br /> IIIN 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# <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> A Property QWItO Inforiiiation <br /> ,4NKJ 1?- 1111( PS 2009 iN cs-- 13a.P2.126- Po as ✓o 62 912Q S03 a*/-9674 <br /> Name Mailing Address _rnCity, State,and Zip (Area Code)Phone# <br /> _... ... ._ B..Legal Property Descr iption <br /> MAP 0�t1!31Go Ion . <br /> • <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Co0.s 1290004.0 12,900000 R. 4012.1 <br /> Subdivision Name Lot Block <br /> 242 gc NO+a/r►a weW L`io NS 0 2 9'73 5$ <br /> Property Address 1 City State Zip Code <br /> Directions to Property: I4Wy 2.1_ LANST 113 06fLak.1(121c (ID <br /> C xiingst F E acility/;Proposed Facility/•Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [Single Family Residence Single Family Residence OPublic <br /> i)) Fled- 2_ Name <br /> Nufnber of Bedrooms Number of Bedrooms Private <br /> Other 0 Other Spring,Shared <br /> c.TIT:T17.9]1V,I;aiiiFi :7..I'::::27f.::,' D.,TType.of Application ,i .... <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ 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 /> - PADAJOLO 2 3-5tS9-Erl I 9 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8S1)2_ 4Stto0wk.) cfS , Sint W 975/7 <br /> 'cant's M iling Address <br /> Signa ure Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative 0 Authorization to Apply form Attached <br />