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' ) Date Stamp: <br /> ‘,1104k.0167.. Application for Onsite For City Use Only: <br /> ='_�� Wastewater Treatment Dig°f (( i U D <br /> Date Received � <br /> mig <br /> System Received by 4/f .AR — 2 2007 <br /> Zoning by <br /> Marion County Public Works MARION COUNTY <br /> .Phone: (503)588-5147 Building Inspection Division Fee P U I L D I N G INSPECTION <br /> -Fax: (503)588-7948 555 NE Court St.,Ste.2260 Receipt# J r <br /> www.co.marion.or.us PO Box 14500 0/- 2i J Qs. <br /> Salem,OR 97309-5036 Activity# <br /> A. Property Owner Information <br /> (Pave 4. Cinch Alme.Adin1e (,cf() AI1' .k/ti . l-p. I(. ke-ze,r.OR SO3 -751.3 -3 ,.s'6 <br /> Nanie. 1vIailing Address City,State,and Zip y,7303 -•(Area Code)Phone Number <br /> B. Legal Property Description <br /> 0 9 3 WG4 •D C) i r7 00 . <br /> • <br /> t...-mi nr_ccrintionTax T.ot Acreage or Lot Size. <br /> _ Red hi et Wk R id (Prvpo5 d) j <br /> • Subdivision Nanie ' Lot Block <br /> Property Address: '154 aamefDi- ,Dr 5, .Sa, lei-vt O.2 9 730 b - <br /> Address • City State Zip Code <br /> Directions to Property: Sr,a /- 1 e r L;b ea./-y Rd. <br /> 14/85 r n C1 /3 .b I" <br /> t <br /> C. Existing Facility/Proposed Facility/Water Information • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑ Single Family Residence ❑ Single Family Residence ❑ Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms igl Private r� <br /> ❑ Other ❑ 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 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor [1 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Temporary Housing <br /> ❑ Record Review 0 Connecting to an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major 0 Minor •❑ Other ❑ 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 /> t)at16ci AJw' end;n0 er SO3-7(7'3-3256 I i07 St <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> (P3/6 6(l•e-kftad Gip . k' kereer O7 `173o3 <br /> Applicant's Mailing Address <br /> Signature ft Date ' CCB# (if applicable) <br /> Applicant is the 121.Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> s-013/05 Page 1 of 2 <br />