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• <br /> somprip <br /> , Ip ;:�N� Application for Onsite For City Use Only: + <br /> L.gyp.•..P i►r <br /> ; � Wastewater Treatment System City of ' V- <br /> Da <br /> Date Received —7.• <br /> Z <br /> MARION COUNTY PUBLIC WORKS Received by 0 a 7 <br /> BUILDING INSPECTION DIVISION Zoning by Z Z cO <br /> 5155 Silverton Rd NE co <br /> Salem OR 97305 Fee "13 0 w <br /> (503)588-5147 Fax(503)588-7948 Receipt# 111 C <br /> www.co.marion.or.us/PW/Buildinslnspection Activity# <br /> ®-< <br /> a A.Property Owner Information z j <br /> Rctl � i 4-v is v 4.014 LA/ 5e -7“rck• otZ Q739a <br /> Nam Mailing Addres City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Gar .731"Xtt003.3t9a:/Iron., rwa73th QgawaKc ol&oo 0.7-4 o,Lre-S <br /> Legal Description Tax Lot Acreage or Lot Size/ <br /> Subdivision Name Lot Block <br /> 85 o& LE Twr✓ .,,. oCZ `�739a <br /> Property Addressn SCity State Zip Code <br /> Directions to Property: QQ�C��(( Q t1 CIL roc�} <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence igj Single Family Residence ❑Public <br /> 4/ wNa�me <br /> Number of Bedrooms Number of Bedrooms I Private "ver/ (P/b pOSG t), <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application - <br /> 23.Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major ❑ Minor 0 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 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 /> g Pe-rC 3-990 -gc7i .4//A <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> gam: V-lye'„9 1-k. c- s e TLdrv1eJ 00._ 9-239 d <br /> Applicant's Mailing Aress <br /> V Lf -i? 4//,4 <br /> Si fri,,,------------ Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative KAuthorization to Apply form Attached <br />