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Application for OnsiteCity Only: c Date Sta.• 0 <br /> For Use <br /> Wastewater Treatment System City of D <br /> 6 _ <br /> Date Received 13 O n <br /> TH <br /> MilMARION COUNTY PUBLIC WORKS Received by _ Q <br /> BUILDING INSPECTION DIVISION Zoning by Z 1\, Tfi <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 '0 L, �s <br /> (503)588-5147 Fax(503)588-7948 Receipt# m C <br /> ww .co.marion.or.us/PWuildinglnspection Activity# 04 <br /> w B . l <br /> iE"__. _.i:was?�ir.�:__T;___-_.. '- -:.....;�__.._____:c�EL:_...z �-Fi: :1-r-:_ .:::- _it-i!i_:_s-__ .e:.vfi='1=� <br /> � .:TF_ar'_.:.::-.r:_vv�'E._�� I. :E .:-.r:r._--.._�:. �_.r :viiic.t.:!: -- ,�'-1��c9z�!�.:!a:l-� -_ - a��i'��__- <br /> =ry:.;_-::.ry}'_,. .!�„��+y1��_::.. T-.,iF.�- '�!.� � �.�zC) e�.{��y�OV1'Ifel�nfdLIIIatIDII � y� =f�' -�yy <br /> ^!4.4ec�W�4e�.'-4.5�?. :�MANh� -=1.:v.:..f .... �..n.--1 r_. ............"�.n 3��-n..r�--':l� --.Y..--:...::. ..... :.. _ ... ..�u,T ... .......:!^dM'P�.i.... ........... ..: �k�.°�v:!:�.e]L a._... .... .... <br /> --r n 1—cz;Irvi is R(%' C-,o0L. r 1-1;.K -.161 , (iZ q73 3)W i-Isoo <br /> Name Mailing Address City, State,and Zip_F._Y. (Area Code)Phone# <br /> T,egaI PS <br /> ar_ . ._ ,_ .._ . _.a..:...:, -_. _: '. open peso _---= _ - . . _... - <br /> 1 p ice: C <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1.-,YOi1 s . ____. C3 - '755% <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> ,.,, 01311.._1_ aasaI A '„,x 4 :t r ' '!*te' orm4ZOn ._ .. _,- --. <br /> Existing Facility: Proposed Facility: Water Supply: �q r , <br /> 4SingleFamilyResidence b Single Family Residence ❑Public Ly0� �4e.jta i 4 bas_ r <br /> l 3 3 N <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> O Other ❑ Other Well,Spring,Shared <br /> . ,:-ri�:.:.r_-_x:a::�a-i::r-=�::::-.i::.. .:. ,._.:....__ :�. �r : .... .:.. _ !::.n:':::K <br /> -j' ���� �....... r' r �E -� �'ype�o�'ApP>icatton � � <br /> O Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> O Repair Permit 0 Permit Transfer ❑ T• he Addition of One or More Bedrooms <br /> O Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 T• emporary Housing <br /> ❑ Major ❑ 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 /> /L.(f lz Q,rk rsc3}t—?1 -L-Igoq <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Ap li is ddress <br /> C/7 11L------- ---------- Vl s g/20 i 6 67-591 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />