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)1--- /19--ial.‘ 6) cic _ l' 0 <br /> Application for Onsite For City Use Only: 0 J Sta <br /> . ~ <br /> / '---'1%------1-1--Ji <br /> Wastewater Treatment System City of 2 : 17x. <br /> --�Y" Date Received s <br /> C) Fini <br /> `' -Mill MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by m <br /> 5155 Silverton Rd NEFee 0 1 fi <br /> Salem OR 97305 =! p <br /> _� <br /> (503)588-5147 Fax(503)588-'7948 Receipt#Activity# �`-- <br /> wvvw.co.marion.or.us/PW/l3uildingInspection <br /> A Property Owner Information <br /> rtY <br /> • <br /> �l-e)1lOcL ex Ct 58jjShaw RoilSE kunst)II(e, OR91325 5o3-9(0-Lit8tf <br /> Name Mailing Address City,State,and Zip • (Area Code)Phone# <br /> • <br /> B.Legal Property Description.... <br /> Legal Description Tax Lot • Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> Property Address City _ St to Zip Code <br /> Directions to Property: 58 214 c8ha L 1--I1. C-- Am <br /> usv l t (..t_l ©K 913 S <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ® Private <br /> O Other 0 Other ell, pig,Shared .. <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 El The Addition of One or More Bedrooms <br /> El Major CI Minor El 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 /> it : At 503-CIO— 4ge)L1 <br /> Applicant's Name—Please Print :gibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> - <br /> 5S2,(0 L( NikliV 111,( d R 9-13 25 <br /> Ir& <br /> icant's Mailing Address ) <br /> ‘C-i611%() - 5—H — I e1 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is thelKOwner ❑Authorized Representative 111 Authorization to Apply form Attached <br />