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f! <br /> 1 , <br /> ., Application for Onsite For City Use Only: Date Stamp: <br /> .nl <br /> ff Wastewater Treatment System city of <br /> Ilii <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by 1ECEovEnn <br /> �p A 9 <br /> BUILDING INSPECTION DIVISION Zoning by M R 1 5 20 9 <br /> 5155 Silverton Rd NE Fee �iti�ilC (( <br /> Salem OR 97305 COU <br /> (503)588-5147 Fax(503)588-7948 Receipt## BUILDING[�c�'� <br /> www.co.marion.or.us/PW/BuildingInspection Activity ���'® <br /> /9-(0194_Lv <br /> Q A.Property Owner Information 7 <br /> Jost-. Gc. ' _ $164 Sfv;eco! LA•M S f lvel c C 1 •/j 3 1 503 • Ito- • 3°9 <br /> Name `� Mailing Address City,State,and Zip (Area Code)Phone# <br /> d 1 W 350 , h «770 B.Legal.Pro QDescription ' 3,53 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> / 1440 8 £✓Ons V4IIei1 ( 1vg. slvetrko,r. off. ` 738l <br /> Property Address /a Ci // State Zip Code <br /> Directions to Property: J4� I e*4- � 5ce t V"4(44404v') eropep Propis 610%. fid(n.- 2 6O 4 e# <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> DSingle Family Residence pi Single Family Residence DPublic <br /> 3 Name 1 <br /> Number of Bedrooms Number of Bedrooms Ok Private (A)CA I <br /> 0 Other 7Cother 5 kap u4 b4EtRwM Well,Spring,Shared <br /> D.Type of Application - <br /> jg 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 /> Jos kwx. Raow563• 110-730`1Applicant's Name-Please Print Le ibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 5-66 cf ects•krieci 66.ek.e_ 1e, s;tueVh1 OR TI3S I <br /> Applicant's Mailing Address <br /> l, - � 2 . 22 _ ( / 22618 ( <br /> la%, -. Date: CCB# (if applicable) <br /> Applicant is the 0 Owner CA'uthorized Representative ❑Authorization to Apply form Attached <br />