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Application for Onsite —l�U at ~ fit <br /> pp For City Use Only: f Date Stamp: <br /> Wastewater Treatment System city of <br /> IIIIIII Date Received E C _,P w <br /> MARION COUNTY PUBLIC WORKS Received by r D <br /> BUILDING INSPECTION DIVISION Zoning by AUG 4 <br /> 5155 Silverton Rd NE • <br /> Fee 201 <br /> Salem OR 97305 - g, a � �� <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# ���-'�� INSPECT �� <br /> www.co.marion.or.us/PW/BuildingInspection <br /> EI; ' .% .....? z. . ,...K. . A Properly Owner Information 4, , <br /> Pr l2 51,11- ---- SGgs Fi-scl-)we4,- Ln k)ac,110u..rtn S)3 3e57 3-772 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> xj f7 g 1 Properly Description.. __ ..�._. u ..... ... _ 'K ._ ...._k. _ <br /> 71,1 <br /> 3-oa <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot l Block <br /> S(,tC l%- rsr�loWel ) (c1-0 l.J0a-iLtt-rr OV X9707/ <br /> Property Address City State Zip Code <br /> Directions to Property: S(o g c r-e..-1,- (-1/) j IC%✓ Ln 716.47,//'V e134d <br /> J <br /> L:77:: . 1, r:` C Existing Faptltty f Proposed ac ity l Water Information <br /> Existing Facility: • Proposed Facility: Water Supply: <br /> DSingle Family Residence ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring,Shared _ <br /> E777-737:77 _ yD T7YRe o£AppItcatian10 x`. 7:- 1 <br /> ❑ Site Evaluation ❑ 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 ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 /> Trc ik S/ t 5-OS 5 -7 S 772 <br /> Applicant's Name—Plealse Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applic is Mailing Addres <br /> j <br /> Rizzi /F <br /> Signature 4 Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ❑Authorization to Apply form Attached <br />