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J 3 -oU 7 ?-5 LPl T <br /> Application for Onsite For City Use Only: PJOIlO�d6Nl bNIG]`ll' <br /> �awN, PP ik�rvri00 N <br /> z Wastewater Treatment System City of <br /> Date Received Cal ?0 3]a <br /> MN MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by al U U [ a s a <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/Buildinalnspection Activity# <br /> A Property Owner Information <br /> e6 AL K tJo Li- .3Zz y ego,kep ci n/r2 .t6 iv I fn f, & fax- <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 072 Og D o020o S <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> a� / d + � A . . fi <br /> Property Address CityState ZipCode <br /> Prh' <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility./Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence t-Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms gyrivate W In L c— <br /> ❑ Other ❑ Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> E.Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> O Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 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 /> 7;;v -t,Z.cii -3"o,?_ 79/- t378 34 71/7 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> lP 77/ PPTgrL RD S 45,/fU1€ , ©j2- 77.z2.s <br /> Applicant's Mailing Address <br /> 1 `, - /2./7/23 72P3 7 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ❑Authorization to Apply form Attached <br />