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RECEn9 23 _00 Liscz Poirti <br /> M",�" 232023 23- 0-0 ( 3SZP�MroI <br /> 444u_ Appliigp,0;o fob, site For City Use Only: Date Stamp: <br /> -��p rR�so <br /> Wastewatt e Eft' stem City of <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 /> :3_a ifillx'.os1 11.7 Di."•. aAizs K.ileef.. #£'sa'.. Activity# <br /> A.Property Owner Information <br /> G�. .���t �-\ P .S. 1 '; w7 lr s'..- l.,0,2J.- ,IL..,e Pin.-�hl- gZi -SO% -g 2?-- - <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Names�r �/ / Lot/ Block �J q r <br /> I r-Wr M='-tA4f'� St�'L/S &r/(< / 1//v�rty — 0 r ! �S <br /> Property Address / City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility I Proposed Facility/Water Information - <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 2 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private ,ii-'e-1 <br /> IR Other 3 ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 Other 0 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-100 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> Applicant's Mailing Address <br /> githSbitia-C W 3. S -3. •Z 3 177063 <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the 0 Owner l Authorized Representative 0 Authorization to Apply form Attached <br />