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091-il" SE- <br /> / / <br /> co C v <br /> Application for Onsite <br /> pp For City Use only: Sak"mp: FEI <br /> Wastewater Treatment System City of z a n <br /> aw..... <br /> Date Received C) INDZ -4 <br /> 1U <br /> Received byZ Ifni <br /> MARION COUNTY PUBLIC WORKS fn n cn <br /> BUILDING INSPECTION DIVISION Zoning by U 0 0 <br /> 5155 Silverton Rd NE Fee 0 Z rn <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# Z ��, <br /> 35 , :: µ;E%A PropertyQwner hformation :-Z y _ =r... <br /> D/9teiA -itreot2 gi-1?3IItiz)04 4Ni SrbiAvN,4R 17381 Jb3-6,32-286/ <br /> Name Mailing Address'_ City,State,and Zip (Area Code)Phone# <br /> e Descn fan tr `' <br /> Legal Description Tax Lot Acreage or Lot Size <br /> g <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property:// vii2 '> e,eyn g <br /> ;,,,,,.. :.: ::::::.:,,..:. Existing 13 actlrtyl,Pr §ed ac Water In on:'.<. ... <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ❑Public <br /> /(/ Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> 0 ,:V . � � g ,�r� �:- .F�-� �� ofAppirea � M4i-i � � <br /> % ,. <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El Minor El 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 /> Dil-t,)d T5t tit iiitrt 5'03--R32--,S.LI 7 <br /> Applicant's Name—Please Pint Legibly Applicant's Phone Number DEQ Lic.aaicable) <br /> i&12c 1ikszigo-4) size) A/ 5-/vt,Y0,1, Pr? 1738' <br /> Applicant's ailing Address <br /> �� ar/2 -120/C <br /> Signatur Dae• CCB# (if applicable) <br /> F,-,c $V3—cr);-./.7 <br /> Applicant is the El Owner El Authorized Representative ❑Authorization to Apply form Attached <br />