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G 3 - 0-05-3Z7 E1HL <br /> ..,,4 :41,,,,„- _ Application for Ons to Far City Use Only: Mate stamp: <br /> i = I Wastewater Treatment System Cis'`of C (� E 0 <br /> Mil <br /> Date Received �1 �' l� �"JL.lI <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by IN 21 2/2' <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 NIP RION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> BUILDING INSPECTION <br /> �li n� � u , � a INSPECTION <br /> A.Property Owner Information _ <br /> ,_. -? . A iInp)) d Naufp1��A 56 APMnaii-Aql3q % 1`"9 r <br /> ame Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> ) fi&ff/C4 P7 Woy /)Li yiwi 67 7-- 5, <br /> Property Address 'J � �i H/ ' ,, tale Zip Code ,��,�/ <br /> Directions to Property: oll leg 2 L� . 7 l 1 iL l t' b /� /f e7/t�LL9 �j%%y /1� IP <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Prep,sed Facility: Water Supply: <br /> ❑Single Family Residence Sing In-Public <br /> Residence Public <br /> Name/ <br /> Number of Bedrooms Number of Bedrooms Private Vv4L,. <br /> 0 Other ETDther TV5,09 it)( Well,Spring,Shared <br /> D.Type of Application <br /> [ f Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ® Replacing a Dwelling <br /> ❑ R!pair Permit ® Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation Q Personal Hardship <br /> 0 Alteration Permit ® Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> if the required fte 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 corrects 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 /> aci / vAi : -� 'l --'NP-.9 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie:## (if applicable) <br /> ` 2, `.'0' /./C5 -4p l 4/ E; fi_umw/u&jet <br /> Applicant's Mailing Ad ess ' / <br /> 1 <br /> Signature Date:O GCB# (if applicable) <br /> Applicant is the Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />