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zZ -6IO1S� - f'r <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> MI <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 /> www.co.marion.or.us/PW/BuildintInspection Activity# <br /> (>o se UV 1'/y Trost- A.Property Owner Information <br /> 54e1e.Sown.. to(oC•/1y e7S7S.W.SKhar)tr, ?or & lore 11213 6-03� il- bl <br /> Name J wiling Address J City,State,and Zip (Area Code)Phone# <br /> B.Let Properku Description <br /> 'r': icy'k.o3 W5:v3 Q .Q't4e oo•. t•K 37321- I At (43,s6o syet.) <br /> Legal Description Tax Lot Acreage or Lot Size <br /> &03w'-3 A R oo300 -' <br /> Subdivision Name Lot Block <br /> i-7-O . k,latt t,h . stS. Je f�ei W\ 14Le. 9-4-3s2 <br /> Property Address 1_ City _ r L State Zip Code <br /> Directions to Property: 'QR.. J 0v� S 0' 4' O>T iS 't,�. O � 1,5l,t r OK pv14,61 Si <br /> 1n v 11 A1s�u\ v <br /> �ln2�n a v�y � n uJa 5 <br /> C. Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms kg Private <br /> ❑ Other _ 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ig Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 21-Major ❑ M• inor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ M• inor ❑ 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 /> iA Wd r,CS# 54k-3 -`-Dlk 39'137 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 4�43 or• %AAA ct-• st;. Sa`ol� 1oi, cti-VI- <br /> Applicant's Mailing`Address <br /> /78`zo�.z 234�-tS <br /> 11C <br /> igna e Date: CCB# (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> ,,r <br /> I <br />