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1 , 7f 7pvi ( <br /> Ud <br /> K <br /> . , z Application for Onsite For City Use Only: D D p: M <br /> �— � City of n <br /> Wastewater Treatment System � �� z <br /> Date Received <br /> i� <br /> Juu <br /> MIN MARION COUNTY PUBLIC WORKS Received by Ct C) ► . <br /> BUILDING INSPECTION DIVISION Zoning by -Q N /, <br /> 5155 Silverton Rd NE Fee C)Z iv <br /> Salem OR 97305 M <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> _ — Activity# • Cti <br /> • A.Property Owner Information <br /> c-mr/?07% ic:.rN'I LlC / 1ccr./c1, ./ _ /e/17 Oe 997305 5V,_) 3 - �l <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> O 3 a-a9 s <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name 2,b‘/f &/% / Lo4fri � - Block <br /> 'r 1 <br /> Property Address City 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 i Single Family Residence ❑Public <br /> 5 Name <br /> Number of Bedrooms Number of Bedrooms ,Ij Private tr-%l/ <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> iSite Evaluation ElRenewal Permit ❑Authorization Notice for. <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> 0 Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100A r g/.. <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if appli able) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> pplicant's Mailing Address <br /> i -16 cZ 177063 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 0wner .334Authorized Representative ❑Authorization to Apply form Attached <br />