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c 0 <br /> .--40 .,..,,7Application for Onsite For City Use Only: et amp: <br /> Wastewater Treatment System city of 2 % 0 <br /> Date Received �}0 73 <br /> Ili. <br /> MARION COUNTY PUBLIC WORKS Received by Z .' <br /> C. i\ <br /> BUILDING INSPECTION DIVISION Zoning by 0_ >v <br /> 5155 Silve• rton Rd NE Fee m C o <br /> Salem OR 97305 Receipt# 0 rd-ti <br /> ece <br /> (503)588-5147 Fax(503)588-7948 p <br /> www.co.marion.or.us/PW/BuildingInsnection Activity# _ J <br /> z <br /> IMElliiiiiiiiiiiillfibiiiiaiiiiiiiiiiiiiliiiiiiiitiiiiiiiiiiBsiimgmiMtr6iggoaaaggoangnuneaEogugogeegmgagsgini <br /> Andre Le ISlngt('Z(c o 1 eiLarleS, �e (g - 11366 S)3 3bz-lgb- — <br /> Name Mailing Address City,State,and Zip _..-.__..........._...-.-_--.--......._Area Code)Phone# __ <br /> FI � .-.. <br /> Le Proper_Ile5crt tib <br /> eigninlinEEMSI <br /> _...__. ...... . <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 /> BERIMANINIMBIEBEHEICIW4iI5M11.01,414drargillfitairitailleallOMBIRMINFIERI <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Singles y Residence [, .,angle Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private IN i t <br /> 0 Other 0 Other Well,Spring,Shared --__. <br /> ----I T'yp'e o.t3.AP hcation._ ::,.— —g _ _ _ <br /> Li. Evaluation _ 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑`Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor. ❑ E i ting System Evaluation ❑ Personal Hardship <br /> ID Alteration Permit ["tecord Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 Other 0 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 /> • <br /> f)4e-ew Le1S'tnger .—PCZ-- '3b(.22- brecte.n ( t0-112 <br />• Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> •z(Doc) 1 �4 b 1 e l.Q►n e• s , sd ie nk_f prf-cio n 9 736 C ' <br /> AlJicant s Mailing Ad ess <br /> p <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the"Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />