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a-5 -06afSa� pp r <br /> ,,,,,, ,,, Application for OnsiteOnly: Date Stamp: <br /> For CityUse <br /> —aY. WWastewater Treatment System City of <br /> Date Received C / f <br /> MIN MARION COUNTY PUBLIC WORKS <br /> Received by L V,,,-D <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MAR 1 s 1023 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARI pN <br /> www.co.marion.or.us/PWBuildin¢Insaection Activity# BUDDING INEN SON <br /> n A.Property Owner Information <br /> Kie—Ihenr 6.-14), Pb, QU� 8O) uLrorc. OR c/700z_ 93-75V,vpii <br /> Name Mailing Address' City,State,and Zip (Area Code)Phone# <br /> a 9 1 �y / '-t' B.Legal <br /> 0 0 Description 3 Z . :sz <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> /3 '2i' l' k\\ e: Oz) NE 4,4 ro r c* oie 97 z <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Pro osed Facility: Water Supply: <br /> ❑Single Family Residence Single Family Residence ❑Public <br /> 5--iz Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> El Other El Other ( )pring.Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> XConstruction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Lary 0 I � h de,� 503 3 L7 /) 61 37c5po1 <br /> Applicant's Name—Please Print Legibly Applicant's'Phone Number DEQ Lic.# (if applicable) <br /> Pro . (go- ' 57/ e• / c LL 0 2 97iza <br /> Ap . is Mailing Addfess <br /> C L/V\£LI 03Gri " 17 <br /> L Zozj <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative Authorization to Apply form Attached <br />