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G7G -- 2 ( -'U�T7 � �'� <br /> Application for Onsite For City Use Only Date Stamp: <br /> ;-- Wastewater Treatment System City of <br /> am Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by MAY ��11 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTION <br /> wwvv.co.marion.or.us/PW/BuildingInspection <br /> A.Property Owner Information <br /> —5--" 4)1hA'-\ /U Ire r/c 33K93 °Igl'lro4J Av, G,171T� Odd y73 co3 - y3 o - Z) 3 <br /> Name 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 /> 3 3 93 Agi'J O4J 40 6gTcst' Dt, 973 cq <br /> Property Address /� ) City �] Stat Zip Code <br /> Directions to Property: / /i ‘.✓e Z J e x 7 Q ),-,, j"' 9 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> jingle Family Residence Single Family Residence ❑Public <br /> 3 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other • 0 Other Well, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ,'Au orization Notice for: <br /> ❑ Construction Permit El 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 /> s'1Ahh- h ' vk^ Pr/� �039� 0 ^ / 33 <br /> Applicant's NameLegibly Applicant's—Please Print Le 'bl A licant's Phone Number DEQ Lic.# (if applicable) <br /> J) 9 3 o/V v'n , J 4vP be) ire Z-7A ,'7 3 54 <br /> Applicant's Mailing Address ! <br /> ``. S — Z. 9 �, o Z 1 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the 'Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> ...v,,...r r.T,.Tn n.TanCnPrnwfTnv71/MctrTTr1C_n1 n?TCTTF APPT CPPT 7111 R TlnCY Rry 1/1 S MR <br />