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1 <br /> I <br /> Application for Onsite <br /> For City Use Only: Date Stamp: <br /> -a=-y ! Wastewater Treatment System City of <br /> Date Received <br /> MN i 1 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/Buildinl;Inspection Activity# <br /> i :, ;,.n: , ` Property Ov er forma <br /> /94 ,1 /I i,;;e 2/6-ip C�ar7, —,, ateitoN-1P 0(141 ,,i. 7.;„ 3b2_b'©6_'7Z00 <br /> Name ,v jJorkt Mailing Address / City, State,and Zip (Area Code)Phone# <br /> '... .. ,n: -rta 4s , ,,•B Legal Pro erty Des ription <br /> � 6y�.w12o�.3oa ZG � <br /> Legal Description Tax Lot Acreage or Lot Size <br /> O&j 2 1n) I ?... <br /> Subdivision Name Lot Block <br /> 21 571 49-, 6e,24,k, Ise 106 Z4. a O 9-2 )3 7 <br /> Property Address City State Zip Code <br /> t -e-�,-�, Aral. <br /> Directions toroperty: 2n s S G�uQ � , a•st�r4 S tc�,^� <br /> I <br /> . „t ;;, C Pxtstipg Taetirty./Proposed Facility l Wate ,r Informatton <br /> Existing Facili Proposed Facility: Water Supply: <br /> Single Famil Residence 0 Single Family Residence ['Public <br /> q 1 Name <br /> Number of Bedrooms Number of Bedrooms 14 Private .e/ <br /> ❑ Other .J Other$,Apa-, pfrso__ ap Spring,Shared <br /> c; s5eA .� Z a� „� .- D-;,T:YI -9. plica ,.rrion <br /> 1161 Site Evaluationb ❑ Renewal Permit ❑Authorization Notice for: <br /> 'Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major11 El Minor ❑ Existing System Evaluation ❑ Personal Hardship • <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major1 ❑ Minor ❑ Other ❑ Connecting tol an Existing System Never in Use <br /> (over 5-yrs old) <br /> ® Other—Please Specify A1£ED Sep{':c-6;,--ea.4. <br /> If the required{le 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 /> ,1 <br /> / 40 Ati;DE sots) .03 —.4( — 7ZD0 • <br /> Applicant's N aln <br /> `e—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable)• <br /> 21571 c I.ia,,.pe-e C2a2,L Ca..l€ NE CI' PaLS a - ate, 9-7 /3 7 <br /> Applicant's Mailing Ad , <br /> L.f 2/ /zo23 <br /> Signatu Date: CCB# (if applicable) <br /> k <br /> Applicant is th Owner ff <br /> ❑Authorized Representative ❑Authorization to Apply form Attached <br /> g[I <br /> P' <br />