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r <br /> ,, ,,,, Application for Onsite For City Use Only: CO Date S. <br /> Wastewater Treatment System City of D <br /> Date Received �_ O n <br /> I- MARION COUNTY PUBLIC WORKS Received by ,0 ni ��v <br /> BUILDING INSPECTION DIVISION Zoning by Z N U ��i1 <br /> 5155 Silverton Rd NE Fee NC) cc) r <br /> Salem OR 97305 -0 O- <br /> Receipt# <br /> (503)588-5147 Fax(503)588-7948 P fn :,'� i <br /> www.co.marion.or.us/PWBuildineInspection Activity# <br /> ;� = z- __ _ <br /> 1-' + �roF"C6E'P.r LLGUCF 7.0 — -_ _� 1,:z2—� <br /> -Be oteen }—a,•ry r,s I l(%,-1 Go ltQ.r I K L �i�cs C 12_ �'73 (5d3) 1—I <br /> Name Mailing Address City,State,and Zi• (Area Code)Phone# <br /> iY.w -'1- A4i t "yLt h a B,c u E `� —mot- f. i` _ `r_ <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Lyc t 0 , Q7g <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> -- �— ,.. ,.;_...:.7 lagL; 4olim.�� 0' . tgym . 94. , �.. —:.1...,-.0. <br /> Existing Facility: Proposed Facility: Water Supply: , <br /> KI,Single Family Residence 6 Single Family Residence ❑Public L O vt //'t1 elta i (A(_( f <br /> 3 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> 1 - -fir-= —�'k -� - _ _ ��_ _ _ _ -- -t-�'.-F-' <br /> _ 5 u 1afE- =' -'�� :P.�C#JT a s�'hCatl' �E-__? — - — �m'�'�:��:� <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> 0 Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> O Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation 0 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 /> //( 12 u3 aCcoet,rks C5 c3 t-?I-L(9D C <br /> Applicant's Name-Please Print Legibly Applicants Phone Number DEQ Lic.# (if applicable) <br /> '-6 . -Box, '?j_7 (._��ri� n� q7�5s <br /> Ap lip t's d dress <br /> q_.L.--_ -,/2--' /2,D I G 939`i <br /> Date: ' CCB# (if applicable) <br /> aPP ) <br /> Applicant is the 0 Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />