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Application for Onsite For City Use Only: ---:"1 <br /> --� ;l Wastewater Treatment System City of RR C V L <br /> Date Received <br /> ...:_-,/�g <br /> MARION COUNTY PUBLIC WORKS Received by JUL 05 2018 �� <br /> BUILDING INSPECTION DIVISION Zoning by 7 <br /> 5155 Silverton Rd NE M'ANION COUNTY <br /> Salem OR 97305 Fee <br /> Bu6l.eDINC.-r. INSPECTION(503)588-5147 Fax(503)588-7948 <br /> Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> t _ «M, M ...... A,PSopertEPYT iinformattari i . �. A laiimi... <br /> 3PCm/LEL SE 825-3 --tom i f St 7,,zxl- OIL 9239E 5-02-93Z-5 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone,# <br /> B Le a1 Pro e Desch tion <br /> - Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1 (,,..04,44L__ De- Ir?"3?Z- <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Existing F'ralfy/Proposed Facility f Waterinaa'a on <br /> Existing Facility: <br /> Tzosed Facility: Water Supply: <br /> ❑Single Family Residence ingle F ily Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms XPrivate <br /> El Other 0 Other Well,Spring,Shared <br /> K <br /> ., s D T e oPA hcation c " <br /> .....�.,..,.�.,,, . ,:: ..._�__,� �u._. ..... . �,.,.,., ..K.,...�Y.l?�A...�.,.�pR__._._ _ , K .,,, x. K� .�ti.,... � w...,_.����...,��-.,,.; <br /> El Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> 0 Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> Repair Permit - ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ( El Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ;Al Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> ) 0 l' - lis4' c ) 5 03— (O 2a?Y 35(aa& Gey L ficc) <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if app icable) <br /> Po sok. Li5 D Ctt,L,� Die--- 97335 <br /> Appli -- s •a -. Address <br /> 7 /3 / 5- 7774( <br /> Si•,.ture Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative El Authorization to Apply form Attached <br />