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Date Stamp: <br /> 6, Application for Onsite For City Use Only: N5.12_64i f lVPi e <br /> „044041,,„.t. <br /> City of - SEE 12E0 EWAC. <br /> ��%� Wastewater Treatment Date Received 1 -- DO 5-27 l <br /> owlSystem . Received by <br /> ' Zoning by <br /> Marion County Public Works Fee <br /> Phone: (503)588-5147 Building Inspection Division <br /> 555 NE Court St.,Ste.2260 Receipt# <br /> Fax: (503)588-7948 <br /> www.co.marion.or.us PO Box 14500 �� . <br /> Salem,OR 97309-5036 Activity# -1tAZ2� <br /> A. Property Owner Information <br /> • <br /> c-Sal)(09nn61. /Iiizhek Z`i55 S hitAiy 215 Mofaffa OAC crX31 0-0050q-z3/4 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone Number <br /> B. Legal Property Description <br /> 2.... a c- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name C Loth y� Block <br /> Property Address: /2,1330 A1 ,t t_ L' r Si l V IV) "e-- q77( <br /> Address City State Zip Code <br /> Directions to Property: <br /> . <br /> C. Existing Facility /Proposed Facility/ Water Information <br /> • <br /> Existing Facility: Proposed Facility:. Water Supply: <br /> ❑ Single Family Residence [ingle Family Residence ❑ Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ErPrivate <br /> ❑ Other ❑ Other we ;Spring,Shared <br /> • <br /> D. Type of Application - <br /> ❑ Site Evaluation ❑ Renewal Permit ❑ Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Personal Hardship <br /> ❑ Major 0 Minor ❑ Existing System Evaluation ❑ Temporary Housing <br /> ❑ Alteration Permit ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major ❑"Minor Cl Other 0 Other.-Please Specify <br /> If the required fee and attachments are notincluded 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 /> M- Anna / 11H f i'eff 63_�OI Z i4 <br /> PP <br /> licant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 2. 55 S. iiwy M NAa.ckao- df cri <br /> Applicant's Mailing Address <br /> Signature limp Date CCB# (if applicable) <br /> Applicant is the [wner El Authorized Representative ❑Authorization to Apply form Attached <br /> S-013/05 Page 1 of 2 <br />