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023- csb Log,Lk-2- <br /> for <br /> Application Onsite For city.trio 01*1. Bac Sbnip: <br /> --- -:.-1,=-_-7---- Wastewater Treatment System City of <br /> ---nsi -E C--E[I V E .----1 <br /> 1M MARION COUNTY PUBLIC:WORKS Onte'Received <br /> Received bv _:..._..j./.. <br /> 11 223 <br /> BUILDING INSPECTION DIVISION Zoning:bv AUG 0 <br /> SISSSilverton Rd NE. Fee- MARION COUNTY <br /> .Salem OR9130.5 <br /> (50.3).5$3-5147 .Fart(503)-588,-7948 Receipt4 BUILDING INSPECTION <br /> Activity 4 <br /> www.comnrimor.usiPWiBuildinolnstiettion <br /> A.PrOpatty Owhartafointation <br /> David Holloway 3095,Molaita Rd NE Woodburn.,OR ,(503)9841,1060 <br /> Nettie :Mailing Address City,State,and Zip (Area Code)Phone 4 <br /> . . B. Legal Property Description • • <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 3096-M0101a Rd NE Woodburn OR 97071 <br /> Property Address City State Zip Code <br /> . Directions to:Property; <br /> . , <br /> C.Drittlag,$#ility/Proposed Facility/Water Information <br /> Existing Facility:. Proposed Facility: Water Supply: <br /> OSingle..Family Residence 0:Single Pain&ReSidefice DPublic <br /> 3 <br /> liAwle.....15 Name <br /> Number of Bedroomi umber of Bedpan:ins 4Privto <br /> 0 Other 10.Other Well Spring,Shared <br /> D.Type of-Application • <br /> 'Site:Evaloation 0 Renewal Permit ['Authorization Notice for.: <br /> rl: Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling • <br /> ,Repair Permit 0 Permit Transfer El TheAdditiOn of One or lviere.Bedroorns <br /> r. Major 0 Minor 0 E:cistingSystem Evaluation El Personal Hardship <br /> t4 E <br /> :atiort,poorhit 0 .ReCord Review <br /> El Other. „ <br /> 7„r El TempOrary Housing <br /> El Connecting to an Existing System Never in Use <br /> 7MajOr 0 Minor <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> II the re4nlred feiand etfictehthenisare not'inc w&yith this application,it'will be tetitractl to;.7on as incomplete. <br /> Post.the,orange card atthe.entranCe tothe property. FiAg the test holes. <br /> By my signature,I.tertifythat the inforniationl have,fiimiShed is correct,and hereby grant Marion County,authorized*oat of the <br /> Department of Environmental Quality,rpermission to enter onto the above described property for the sole purpose Of this application.: <br /> Lif.stinky Env Service!Chris Clasen ( 03).4.51-8.715 p8231 <br /> Applicant's Name—Please Print.Legibly .Applicanes-Phone Ntitriber DEO Lie,If (if apPlicable) <br /> 19631.Kolar Dr,-Oregon City, OR 97046 <br /> AppliCant's Mailing Address <br /> •. el " C ------ - 2. 1-0'-1X3 139693 <br /> Signature Date: CCB4 (if applicable) <br /> Applicant is the El Owner gj AtithoriZed Representative 0 Autherizatien.to Apply form Attached <br /> . . <br />