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21— OoT754 <br /> A Application for Onsite <br /> pp For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of111111 <br /> -- <br /> 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 /> Activity# <br /> A.Property Owner Information <br /> 1-1- Ills e x e ? l yov,s e7r 17.3-Sg- -5 73—7 7g 3( 27 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal r Desc tion <br /> �FX kl A1�/ q S L=L.( 8— z) 5 /gq l_vl 2_67-- 6.7 Z <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Z5,-ees-/ A rL- / u or- 'S 2 <br /> Property Address Cityd State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence igfSingle Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring.Shared <br /> D.Type of Application <br /> D Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major $Minor 0 Existing System Evaluation 0 Personal Hardship <br /> 0 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> Applicant's Mailing Address <br /> l. r� C W ` 5' la 177063 <br /> i��nature 1 Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />