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.t b � <br /> - 0\i_, . . •• •-: for Onsite <br /> ���' °w„� YY For City Use Only: Date Stamp ' <br /> - --ate Wastewater Treatment System City of - <br /> p - Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION . Zoning by , <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> w .co.marion.or.us/PW/BuildingInspection Activity# • <br /> ww <br /> 4 .E, A$Property Owner Information 7.y 1, i <br /> • <br /> Le_Oliti d F-olLs\ s(.tis %u:l?t e,s ( .S `So,�e_w, , 0E2_ oCl 3o(. ci-t(-21 `1-5 S <br /> Name Mailing Address .City,State,and Zip (Area Code)Phone# <br /> RE- F .,.,x N .y” riEN u$Leal`PrOpert}!�eScnpt10P1 f,.....F. >ka, n. .k_ x._� <br /> �.1-4 0o �" 'Z.OQ <br /> Legal Description 11 • Tax Lot Acreage or Lot Size <br /> C_rCJ I Sa vA �Vit" C�\�' P‘c..d`ES i <br /> Subdivision Name . Lot• Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> G E1*tin FacElt i Pro osedFacih . nater Info nation <br /> ... gam<._,.,ty ...P.�,�-. ,.._-�tY �S�F-_�.� ,, .,�. .,..>7.,g,-.b._, tiikaii-PM*,V M <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ![Single Family Residence 171 Single Family Residence ❑Public <br /> 2 3 Name 9 <br /> Number of Bedrooms Number of Bedrooms ] Private irUe/�L <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ;', D Type of,Apphcati on =._._._ES. -. x x_ , _>._._ _ <br />• <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Aut ►zation Notice for: <br /> ❑ Construction Permit El 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 /> • <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 Ihave 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 /> Applicant's Name-Please Print Legibly Applicant's Phone Number • DEQ Lic.# (if applicable) <br /> 5-6G S (.20-'\&.S's 6-4= . <�� Oma-- Cil 3 0 6. . <br />• Applicant's Mailingg�Ad 'ess • <br /> Signature Date: / / CCB# (if applicable) ' <br /> - - Applicant is the 0 Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />