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• <br /> . <br /> ado L\�Rg <br /> • <br /> r®:ECEV <br /> �,.... Application for Onsite J�N �.2 ZOZ`: <br /> For City Usc Osly: <br /> Wastewater Treatment System eltyof <br /> Date Received <br /> • <br /> ----_ 1 RION COUIii TY'I'tJBLIC WORKS Received by <br /> B'LJILD1NG:INSPECTION DIVISION Zoning'by <br /> 5155 Silverton:ltd'NE <br /> Fee <br /> Salem OR 97305 <br /> :(503)588-5.Y%17 Fax(503},5884993 Receipt i# <br /> ______ o manoa.orns_____ildin In ection Activity# <br /> A..Property Owner lnfermat on <br /> Name Go- f . <br /> I41ail�ng Address City,State,;and`Zip (Area CQt <br /> B.Le 1.Pro • <br /> ga perry Description <br /> LegaLDecdption <br /> Tax.Lot Acreage:or Lot Size <br /> Subdiuon Name <br /> Lot Block <br /> 'Property Address. .p CoDirections toProperty • City' State Zip C <br /> • <br /> C.Existing Facility I Proposed Facility I Water information <br /> ExisiiIIg Facility:',„" •• Proposed Facility: <br /> mgleFamdyResidence <br /> Sm eFamd.Residence bh <br /> �}, Water'Supply: <br /> Y <br /> ., <br /> Number of Bedrooms. — Name <br /> Number ofBedrooms <br /> a other • • CI other 0 Private <br /> ' ,:D TYPe‘of Application -. <br /> ' ❑ Site Evalnahon <br /> Renewal Permit <br /> e <br /> i� ConstnichosPermit < r ..per �utlionzatt©nNotice for <br /> Wig;S <br /> ❑ Reinstatement . <br /> %.' Permit �,; � � ®n�I2epLi+cmg;al)we��-'��,�,// <br /> ❑.tiennitTtansfer ""` or if'ot . <br /> P! Major ❑ Minor, ❑"Existin S ' -Personal <br /> ►ardshipTi orMo,. " <br /> g ystem Evainahon <br /> Alteration Permit ❑❑s Tersonaasy Hou ip n <br /> �_ .: • - ❑ lecordlteview �:� <br /> 0 Major '❑ Minor' ❑ Other 0 TC nn ctmgto si <br /> - onnectingtn aa$xisting <br /> m (over 5-yis olds <br /> 0 father—Please Specify <br /> I the., r ' f required fee and:attachments are not included with thi vpplication it will be'teturaed to you as incomplete.f- Postthe Dian a care atthe♦entranne a the, o <br /> ..• ' (y, Tin the test:holes, 4 <br /> a Bymy.signature,I�certify that the information.T have:furnished is correct;and hereby grant Marion County,authorized <br /> Department of Environmental:Quality,"permission•to enter onto the above described <br /> '� . property for the sole purpose a f the <br /> y, <br /> PmP <br /> Applicant's Name-:Please'Print Legibly pplicantis Phone Number' <br /> p DEQ Lic # (if apficable. <br /> Applii%ant's .lini,,,Address <br /> z i: . <br /> D at e: <br /> ccs tr <br /> gaPPltc ihk} <br /> . ` <br />