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dli.. 664 -1Lio <br /> ,................_........, , <br /> dJ <br /> , <br /> Application for Onsite <br /> T- City of <br /> w , <br /> m <br /> astewater Treatment System <br /> [-s.ECEVED <br /> Date Rmelverl <br /> Received by <br /> s... / MARION COUNTY PUBLIC WORKS . <br /> BUILDING IMPEL i ION DIVISION Zoning by ., JUN 2 0 2024 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> Receipt'4 , <br /> (503)558-5147 Fax(503)5'138-794a <br /> www.trunarina.nr.usfPWIBliildi 1 ectinn Activity fi <br /> A,Proputy°timer'Information <br /> 3/77 <br /> at._ 9735T jot,,,,6-05 sit-,-to-c4( <br /> Name MItilkg Addrss City,State,and Zip (Area Code)Phone 4 <br /> B.Legal Property Description <br /> , . <br /> Legal Description Tax Lot. , <br /> Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 'L4itf"40 ALSvitia.-- qui t,4+.2 - .. 4.p., Kr— OK_ 47. -1357) ....._ <br /> Property Addressg . States Zip Celle <br /> Directions to Property: O.0.. 22- <br /> , ,, • <br /> 3_,--+0, urt vet-A) <br /> CB:xi:Sting Fatality/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> kiSingle Farnil Resi.-,cc - ,rogic Ft. il. v Residence APublic <br /> ...to Name <br /> _, 111, <br /> Nurnb.-: -:al *Oil.. Number ofBcdrooms Pnvat" c <br /> 0 Other Well,Sprint, Shared <br /> DITYpialAppliCan-on .. z' <br /> El Site Evaluation -'- 12 Renewal Peimit 0Authorcza* tion Notice far. <br /> 0 Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> EJ Repair Permit . 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major ) kilinor 0 Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor .0 Other , 0 Connecting to an Existm" g System Never in Use <br /> (over 5-yrs.old) <br /> 0 Other-Please Specify <br /> If the requiredfee and attachments are not included with this application,it will be returned to you as incomplete. <br /> Post the orange card it the entrance to the properly Flag the test holes. <br /> By my signature;I certify that the informationfami <br /> shed 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 - e <br /> I 1Ail I-1,1 AC4---• g6-1ACkli 1 503-33J -5-77•tic t <br /> l Applicant's Name-Please Print L4Ily Applicant's Phone Number . <br /> DEQ Lie.Pr (if applicable) <br /> pc, ge.r.„ ,9-1).57) - rerzeif Da- 9 736' <br /> Applicant's Mailin.o ddress <br /> / . 2-&-. — V <br /> "..,:-• . Date CCB# (if applicable) <br /> Applicant is the Downer. • - 0 Authorized Representative El Authorization to Apply fona Attached <br />