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• <br /> ,, „ , Application for Onsite For City Use Only: D e <br /> 4j-. City of , <br /> _--,_„; Wastewater Treatment System <br /> MI - Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> JAN 16 201 . <br /> • <br /> BUILDING INSPECTION DIVISION Zoning by MARION COUNTY <br /> 5155 Silverton Rd NE Fee BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt#Activity# (�-�c�y 2c� <br /> w <br /> ww.co.marion.or.us/P W/Buildinglnspection <br /> A Property Owner Information <br /> LQ.O14°a coks . s0.s sal?rnc& a. .. .. Salmi., 02 47306 q'it —zi ,�-scs6 <br /> Name •Mailing Address . City, State,and Zip (Area Code)Phone# <br /> B Legal Property Description <br /> Z,06.,. A_ .. <br /> LC-O e S0.ti Q ..�. of 'E., i <br /> Legal Description Tax Lot Acreage or Lot Size <br /> ' 0 V4 tA1 %'3 c_ 02t-t co <br /> Subdivision Name Lot Block <br /> S4q diver da`e_ a_; c Scx1e)v1-. Ott Cf 3fl Z <br /> Property Address City State Zip Code <br /> Directions to Property: - <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single Family Residence 4 Single Family Residence ❑Public <br /> . Name <br /> Number of Bedrooms Number of Bedrooms 1 Private t.iJ�1,1 <br /> ❑ Other 0 Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> • ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major iC Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing . <br /> El 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 /> L-eo tik i ci V-okcctnc C1'-1 1-2_1 t,—SSS b <br /> • Applicant's Name—Please Print Legibly . Applicant's Phone Number DEQ Lic.# (if applicable) <br /> S G6 S eke v,c,S c . S . Sake_ . ®2 ctrl3©G <br /> Applicant's Mailing Address <br /> 6 ___e_, ii,41,__, - <br /> s, k 0/2_s/-t.of-1 <br /> Signature • Date: CCB# (if applicable) <br /> Applicant is the kfLOwner ❑Authorized Representative ❑Authorization to Apply form Attached <br />