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,, .„,,,_ Application for Onsite For City Use Only: Date Stamp: <br /> --'17 -7.-�� Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> • <br /> A.Property Owner Information \)\530--k <br /> 517 (MMD e041-1.41110-1 s(o' '7 ZESNA RDAtl,L 4-cAS,t4,ok 97&pit- M%}€1 2,-2459 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> -r S, Q;(4 . Z. B.Legal Description 4E7. 4-g <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> /Mgt. r- ►.tt (44. % J= 2-5,ar 1,12. q.7;50- <br /> Property Address City State Zip Code <br /> Directions to Property: 5 aC.rf4 to,/...t I--' rrj ,zcie LLQ rt 5 vv� C t. j <br /> __1„ .._4421___7...4- 0.A1i 77, s ,-r I d- nl A.AA P 6wes-r tm MIL yr? <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 /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> 0 Other El Other (,t)(tsiefaX t@-1.1Q TT-5„. ?et7 Well,Spring, Shared <br /> D.Type of Application upeseag r-ZcL`J : iT35.0 GpD) <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Mr Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer D The Addition of One or More Bedrooms <br /> 0 Major 0 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 /> * -VICE C.f.cT r-Ae., - ib �cA1 Mei) S4 (over 5-yrs old) <br /> (447A-L2-4542.- 4T Ti dor d $ x.7i L ❑ 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 Enviro4mv. w <br /> . . Quality, sii/ofi�ntenter onto the above described property for the sole purpose of this application. <br /> C43 <br /> %41_,VAsaviA bv\, 552,- 581 - poi,8 /J <br /> Applicant's Name-Pleas8 Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 2.g'`7 Z2%..A 54 SE 3-t5S Solo ® 6(`) ' 2 <br /> Applic.f, Mailing Address <br /> .7 161 <br /> ,__...... ,A <br /> _...... ---•yr. 5(1-71/4 40 zi 3 /— <br /> Signature Date: CCB# (if applicable) <br /> • <br /> Applicant is the 0 Owner Authorized Representative 0 Authorization to Apply form Attached <br />