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//' O 'a// . <br /> ,t a Application for Onsite For City ase Only: re= ;,?,. <br /> P--- Wastewater Treatment System <br /> City of <br /> y Date Received <br /> ' MARION F Ir£ '�t'�' PUBLIC WORKS Received by jn <br /> • BUILDING INSPECTION CON D�7ON. Zoning by Z 0 rn <br /> 5355 Silverton Rd?tEN <br /> Salem OR 97305 �� C? <br /> (503)588-5147 Fax(903)588-794 Receipt: - '� <br /> vw co.marion.or.ussPWf ildingInspectioa Aelivity Al --k 4 <br /> __ - - - - -. _ A.-Porperty Ow$ne i1 iIII3ti0Il • _.. . _ _ - :_-_ ._ _ -Z• -- <br /> Namelrfa,'iiw,Address City,State,and Zip (Area Code)Phone <br /> --.:.-±::-:-.:---.---.:::".:f."_....::-.:_-:- -- - _ - --_:-;.B_2egal PPoperts'Description --_= 1 -.:-...- -. - : -_ -- <br /> Legal Description Tax Lot Acreage or Lor Size <br /> Subdivision Name Lot Block <br /> I t O CII M 1 S e- o•kv s 5 73'_ <br /> Property Address My State Zip Code <br /> • <br /> Directions to Property; --- <br /> - : -.17:7-?-7777,. 'fl.---7? _- . _ - _-C.-Existm7 Facility:/ProposedPacili[y/;fSTateF:?nformatio :-_-: -_--_ _ _ .- <br /> E•zisYins Facility_ Proposed Facility: Water Supply: <br /> Single Family Residence (:Single Facey Residence [Public -. <br /> 3 Name - <br /> Number ofBedrooms Number ofBedrooms ❑ Private e_,�\ <br /> 0 Other <br /> - -- _ __ - - 0 Other WeSP�g,Shared <br /> ---_-__--- -._, = - -- '.•DT ofA Ication = __ - - <br /> ite Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> 0 Construcdon Permit 0 Permit Reinstatement <br /> Permit ❑ RepIacing a Dwelling <br /> Q Repair Per <br /> 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major Q Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review ❑ Temporary Housing <br /> Cl Major 0 Minos 0 Other 0 -Connecting to an Existing System Never in Use <br /> (over yrs old) <br /> 0 Other-Please Spect, <br /> ?''rhe regrz ecl fee and attachments are not included with this application,itwill he regioned to you as incomplete. <br /> Past the orange card atthe entrance to the properly_ Flag the test holes. - <br /> By my sianature=I certify that the information I have famished is correct=and hereby grant Marion County,authorized agent of the <br /> Department ofEnviranmental Quality permission to enter onto the above described property for the sole purpose ofTis applica on. <br /> _rie.frana -C IAI;Isar JR. 5o3- e 73-7/57 5-2 003 <br /> Applicant's Name-Please Print Legibly Applicant=s Phone Number- . DEQ Lic.= (if applicable) - <br /> 27 1S C S d lidtMu E 5:fUee-4nr, b ' '730° 1 <br /> A.pplicant's Mailing Address <br /> i ---, -,-- f k,,I.J AittfLvi, 9.a S -'1 la— 01 <br /> 3i atur "( Date: CCB# (if applicable) - <br /> k onlicant is the 0 Owner ❑Authorized Representative 1 Authorization to Apply form Aitarhed <br />