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• <br /> ,,. Application for Onsite_ For City Use Only: De aStamp: <br /> X d city of <br /> - �- �� Wastewatei Treatment System <br /> REcElvE0 <br /> Date Receivd <br /> e i'te'iRION COUNTY PUBLIC WORKS Received by APR 0 9 2019 <br /> • B ILDM s_INSPECTION DIVISION. Zoning by <br /> 5199 Silverton Rd <br /> �T <br /> 1.ra <br /> Salem OR 97305 Fee BUILDING <br /> INSPECTION <br /> C <br /> (503)588--5147 Fax(983)588-7948 Receipt# - <br /> arww ca.marion.or.usfPWfB-u2?drna,.Ir2sp ecaon Activity r <br /> A-Proptt Omer i ni on <br /> rip v— / e..9►mac/ d t /lite) s;Greer "r (vr+� 39. 1 Sus—9,a--iyo,•37 <br /> ame Mnitino Address City,State,and Zap (Area Code)Phone <br /> - - -- .. _...- -•-- --- --_ - -- _. -__ --B.LeggalPropertyDescription: . -- _: .._ -- . : __ _ - <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 3777 u+•e...e. Lr, (4J fu r u .r- or <br /> Property Address Cry State Zip Code <br /> Directions to Property; <br /> -- , __' 7-7---77.7-7- - _- - _::C:=F. sr _Fa /Pro osedFa J' a€e • i _- . - <br /> . P. . _ �ifoi�aiatiozz--:="_:;---=`° - . --- --1'--- - <br /> L•-Sistina Facility: Proposed Facility: Water Supply: <br /> [Dingle Family Residence 9 Single F y Residence ]]Public .. <br /> Name - <br /> Number of Bedrooms Number of Bedrooms 9 Private - <br /> ❑ Other ❑ Other <br /> :''.----;.::•.f-..-9.',;-':6--:7=- .:;:-_ - . <br /> - --_ - - D'=T"- eof_ i7.-;-:':"-''.''..1:-7:':,;-;_-_:-2;-; ell-Sgrin�,Shared . - <br /> L Site Evaluation 0 Renewal Peen t ❑Authorization Notice for: - -_ <br /> 0 Constrecton Permit 0 Pewit Reinstatement ❑ Replacing a Dwelling <br /> repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> Er Major 0 Minor 0 Existing_System.Evaluation <br /> (� 44/ton Permit El Personal Hardship <br /> 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 -Connecting to an Existing System 3'srem iveverhi Use <br /> (over yrs old) <br /> ❑ Other-Please Specify <br /> Tithe required_fee and attachments are not included-with this application,it will be reti nedroyw,as incomplete. <br /> Post the orange card atthe enhance to the property. Flag the testholes. - <br /> By my sic _I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department ofRavironmenrai Quality permission to enter onto the above described property$ar the sole purpose of this application. <br /> ,.He"ria 14 IAl j I a,1 0-R. 5 - 6 73-7/57 . . 7 00_3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number. DEQ Lic.= (if applicable) • <br /> B77 Ceic dem ', wf. e -,SS;fWe- _ i2 97301 <br /> .pplicant's Mailing Addresses _ <br /> •1 t { c c. � y 4/'-& J <br /> —1 ` J_ b b <br /> 3i6attlre '( Date: CCB# (if applicable) • <br /> op licant is the 0 Owner !l Authorized Representative ®Authorization to Apply form Attached <br />