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,SE'S'-'rI-00 0 47143-TN Y <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> . 111111. <br /> Date Received i �G• CE \ E <br /> -' IF W1 <br /> MARION COUNTY PUBLIC WORKS Received by <br /> • BUILDING INSPECTION DIVISION Zoning by 1 !' i p N 2 5 2019 <br /> 5155 Silverton Rd NE Fee i�1 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> www.co.marion.or.us/PW/Buildinglnsaection Activity# BUILDING IN`RECTION <br /> t"�' "i 31113. 313 313 3.. '31 3 �3 `�M'�y" <br /> '. __.,.._ 33 _. . .':A Proii 4 ez t'n£ornxation .33.,1.1311.1,3,1a,3,> MEIR.._ <br /> lit: . I ' L. r. '.* O. 'r ling sillkillizt RANG Si\ iec}tw) t9133I 501-dot I- 1530 <br /> Nam- Mailing Address City, State,and Zip (Area Code)Phone# <br /> 3 <br /> 3?r3J..d� ,_. 33 3.1 211 3 ,ipkP40p., 2. 111aa.. ,..,..,x <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1112-4Sc Pabi t w:l l t N S'i Wb n 07, 9'73 81 <br /> Property Address City State Zip Code <br /> Directions to Property: ki 2_A +j S: Alcil el ia.. Ril <br /> ,i. ,, , ;tE C Existing f acility/Pra ased Faclli 1 Watepgnforrnation3 ` <br /> Existing Facility: Proposed Facility: Water Supply: <br /> IXSingle Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> ..4'W31 d 31 9 P �. 3 3 -. V 33 <br /> ... ,.1... .: .... D.mrype of;Appheatlon m 1 <br /> ❑ Site Evaluation El Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor F:/ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> El Major ❑ Minor ❑ 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 /> e)nAcvn 4-V1415+4.1 s9rewe,r— 5t3--v,q 1•- 1530 <br /> Applib'ant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> tin L-S, A-40j4 i94 NE, `ilv�-k) o. c°►-73gi <br /> Applicant's Mailing Ad ss <br /> or <br /> G..:A, L. All. 1-Z --I I <br /> Signa i re ' ' Date: CCB# (if applicable) <br /> Applicant is the IXOwner El Authorized Representative 1=1 Authorization to Apply form Attached <br /> Kv„,,,,,„.„, Q grna,\, cam <br />