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R5- 55 \ <br /> ' ,, Application for Onsite For City Use Only: Date Stamp: <br /> .III 4pN'� <br /> - ---- Wastewater Treatment System city of <br /> miii------- Date Received <br /> 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/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> r G,E 4 o s PR ,92.15 �! ca.7I 'icy <br /> Name Mailing Address Ci , tate,and Zip (Area Code)Phone# <br /> ,B.Legal Property Description <br /> - <br /> d02_ Li �j L(L Rd. St <br /> Legal Description e,n !� 7-23.s u Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions s to Proper (0y: ^ 2� 4 0 1 Lr it 4. ��_�j ( c>il C Pre-ita_ <br /> • <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: r osed Facility: Water Supply: <br /> f(mg1e Family Residence Single Fatly Residence ['Public <br /> — <br /> CI_J� Name <br /> Number of Bedrooms Number of Bedrooms [rivate <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> 127Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement 0 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 /> Applicant's me—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 23C'1f7 L,D � 10 Lf ;,)z Z oj p- e)/Z 92 7 <br /> App 's Mailing Address <br /> 1 "' ' i 6 . -2a23 <br /> Sig e Date: CCB# (if applicable) <br /> Applicant is the®'Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />