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0 ?-gi- ,I've °° o <br /> Application for Onsite City y: tem <br /> 1 For Ci Use Only: p: M <br /> Wastewater Treatment System City of Z Mev <br /> Date Received 0 0 73 <br /> Z ~' i, <br /> b <br /> y <br /> MARION COUNTY PUBLIC WORKS Receivedz n , o <br /> BUILDING INSPECTION DIVISION Zoning by 10® N c <br /> 5155 Silverton Rd NE Fee m c <br /> Salem OR 97305 Receipt# C)Z .I. <br /> (503)588-5147 Fax(503)588-7948 P --i <br /> www.co.marion.or.us/PWBuildinglnsaection Activity# 0 t, ,I <br /> Z <br /> l til_.. al ''A Property OwnerInfbrmattort '"" _...,. ._._. l,,.. iggi <br /> S L'L r vk l 411(d✓ t-(-i'3e, Mu -/- l( /5f -7-(004,1 ,, Gi? 9-312 6a -4007- Z 21(/ <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B Le al P o e Desch tion, , <br /> 'e Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 473.6 / to i or 9 7 7 , <br /> 'roperty Address City State Zip Code <br /> Directions to Property: <br /> .. _ . ,ExistinguFactlity/Proposed Facility!Water Information.. .. ..._._ .__.._.. .'._. , _ .:_._ I;_..__.. <br /> Existing Facility: ProposedV,Single <br /> Facility: Water Supply: <br /> ,Single Family Residence Family Residence ❑Public <br /> 1. Name <br /> Num er of Bedrooms Number ot Bedrooms slg Private <br /> O Other 0 Other ASpring,Shared <br /> E D Type of Apphcahon ib , __ . <br /> ❑ Site Evaluation ❑ Renewal Permit MAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 'i, The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation • Personal Hardship <br /> O Alteration Permit 0 Record Review ❑ Temporary Housing <br /> O Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 theproperty. 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 /> ti7tC.(c C. rs3S 563 9 Co-12 (3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 'frs -c if (�£ ----nofri)ernr 973CJa <br /> Applicant's Mai ' _Address <br /> lir"' ' 0 vile/7_077 / 7)Z/D <br /> ature Date. CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />