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W� <br /> Application for Onsite For City Use Only: E tamp: IJ o <br /> s. = ���- Wastewater Treatment System city of 0 <br /> Date Received 0 70 <br /> -.. t, U IJ IJ <br /> MARION COUNTY PUBLIC WORKS Received by z c. 1„ <br /> BUILDING INSPECTION DIVISION Zoning by 0 >v <br /> 5155 Silverton Rd NEFee MC <br /> Salem OR 97305 Receipt# 0 Z M <br /> ece <br /> (503)588-5147 Fax(503)588-7948 p <br /> www.co.marion.or.us/PWBuildingInsnection Activity# 0 <br /> z <br /> _.__._'. _.,.___'_ ,ti _v T A Pro e Owner Infomi tionL,_ _.._ .. .__'.' <br /> 3� .�,,_w,_ a_....�a <br /> ' . .,, ...�.___A <br /> 3 <br /> Ii7d c4 Le «l 11qtr Ofo6O ale,LArlest ry,(0,1k OF- ,- 11 ad(9 c3 3bz 7A b2_ <br /> Name Mailing A dd ressCity,State,and Zip (Area Code)Phone# <br /> B Legal Property Descnptton <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> L_. .. . ,3,µ. C Bxistxng Fa OY,i/Proposed,Facziity/Water Information', ,l w„ _11 3 _ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> El Single Family Residence 'ingle Family Residence OPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private 'N e+ II <br /> ❑ Other 0 Other Well,Spring,Shared <br /> s '_ 3 FD T e of"A hcation E <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0—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 /> n4( N Le ctngef S7i3--�GZ_- 1,��2,- t5re1en ( - (( L q2 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> -z-c,c,,o p__(,„6f e. Lade s. , �A1Ef& Oron , 736 <br /> Ap I licant's Mailing Adi ess t IP <br /> 1' tf1l <br /> .1; JCS. • ` f z z, . i Y iuk <br /> Signature i Date: CCB# (if applicable) <br /> Applicant is the1Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />