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a ,t gc0-3‹ <br /> ..,,,da,„.... 4N,, Application for Onsite For City Use Only: C ' s r' • <br /> : Wastewater Treatment System City of o a <br /> Date Received 222 = <br /> 111111 <br /> MARION COUNTY PUBLIC WORKS Received by 00 <br /> BUILDING INSPECTION DIVISION Zoning by Z 0 <br /> 5155 Silverton Rd NE Fee -© l'''.a <br /> Salem OR 97305 mc <br /> (503)588-5147 Fax(503)588-7948 Receipt# 0Z <br /> can Iffil <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# 5� <br /> Z CD <br /> A.Property Owner Information <br /> ,)5,1-nes A, Nye il0 Ai ivervpen 4v` 56erytcri3OF'ic17 3 56;'-5541-ZeZe <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 10 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 123/V tiJ Stay cn. gel Avin ivi'fk eP._ 973Z5" <br /> Property Address City State Zip Code <br /> Directions to Property: Si cykii roue.) 6 L✓U5/ .S 41141 rock() 714h 10,'1, r i jAf IP I mile_- <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 10 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms (l Private 1.vf;;(( <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application., <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> O Repair Permit ❑ Permit Transfer D The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major 0 Minor ❑ Other 0 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 /> DepartmentC?a . <br /> / of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> on,/ cM, LLc . 5D 3 - 36a • 3/135 3/0/0._ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> q/9 I'' hbe►- flufrl5(f///€ D R q73 ?.5 <br /> Applicant's Mailing Ad ss <br /> qC;i: ,&\•- ULO•Jk_ D,Zaz_ .p.\.1-6 \.1, g1.0 .-)s- <br /> Signature Date: . CCB#'(if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative D Authorization to Apply form Attached <br />