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i / -oo 3 3 7 2— Etial <br /> ,, , ;,,,,zr. Application for Onsite , For City Use Only: Date Stamp: <br /> =5-" Wastewater Treatment System City of • <br /> am�' Date Received FilECEVED <br /> -.MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> • 5155 Silverton Rd NEFee MAY 0 9 2019 <br /> Salem OR 97305 Receipt# MARION COUNTY <br /> . (503)588-5147 Fax(503)588-7948 Activity.# BUILDING INSPECTION <br /> • www.co.marion.or.us/PWBuildinglnspection <br /> _.: o e. Owner Information <br /> ►/Ai%iD 4, G 1e .,� .p(el : PO (��,'� 5b3 �ilv,5i itlg �7,3V SO3-932, �SvZ <br /> • Name Mailing Address City,State,and Zip _ (Area Code)Phone# <br /> t :r B <br /> � . .. .. <br /> 4. <br /> Legal Pra-ems Description <br /> NA i1-0./\)70i.-iii-Ttillowv.511,1 <br /> 1. 100 ' <br /> < < <br /> Legal Description 3ec%lo,/ /g /y NW//t! u Tax Lot Acreage or Lot Size <br /> Subdivision Name <br /> i Lot Block <br /> t <br /> r <br /> `t1 3' Sr i4r //llo .O1\i&-- <br /> op " 1 f + <br /> (.' -;,zfit\ J / <br /> .Property Address i Ciliv State Zip Code • <br /> Directions to Property: 1 rvr'Yi /(T old eA5 -o'n t. <br /> .4 1 ur IA ISi: 4 Oh 1,rev Vet( l l'uf gd !UC, ',.2P , <br /> iJrst AIM-art (11eK INP , , ea51 n1i1 irn LeLi- ci I��i�t`iIr \ nv cof . ri; i`, IA- i5on a ae'cx: .rAId'.0A• <br /> _ 6, ; C.hadsting Fad*/Proposed Facility(Water Information - . <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 10 Single Family Residence ❑Public - <br /> Name <br /> _ Number of Bedrooms Number of Bedrodms Private <br /> ❑ Other <br /> ❑ Other � <br /> Shared <br /> . e:i APhoatio---__-"- Tr- -7- - - - -- - <br /> t <br /> Dil Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . ❑ Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation D Personal Hardship <br /> ❑ Alteration Permit El Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 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 /> • <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> / 5v3, 521 G <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Addiess <br /> I / ... 5/?/, . <br /> Signa i e Date: • CCB# (if applicable) <br /> Applicant is the❑Owner F4 Authorized Representative ❑Authorization to Apply form Attached <br /> mar rvoiumcPPTrrc_nt ANCITP APPT.SRPT 2018.DOCX Rev 1/15.3/18 <br />