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,,,,,, Application for OnsiteForCity y: ® I[C f ftf I5 <br /> ,ni � �� Use Only: I� e <br /> ......,>:__________s__4 Wastewater Treatment System Ci of <br /> Date ReceivedIIIIII p� q�p <br /> MARION COUNTY PUBLIC WORKS Received by JUN 0 S 2010 <br /> C� <br /> BUILDING INSPECTION DIVISION Zoning by MAR ON COUNTY <br /> 5155 Silverton Rd NE Fee E3U1LDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# (. .-001--(37? <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A -Pro ert Owner Information <br /> Schlech1ey, Maty 7 UT S}rrncy Lyl AJ, c wa.is, 012- g7-oa4o <505) 510-7432- <br /> Name Mailing Address City,State,and Zip (AArrea Code)Phone# <br /> Legal Property Description. , a <br /> �S z A ((C.._. �..__ _ . I_.3-1 61eA4/,: <br /> �n�'ru��s - z��rucQss - �I �o f <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> igZS siltryle,yLavieNE C?cvais OW- c11'o2-(0 <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 y Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Private Well <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application , <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> �] Construction Permit IIIPermit Reinstatement ElReplacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 /> Ma►i D. Soh 1ec,hJam.- 503 - 510 --743z. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> —1gz8 54-a ey Lupe- !Qt. Ge.tr-va.is, Otv q7-0z1, <br /> Applicant's Mailing Address <br /> J,{c+A.0. 0. S ch(e CAI be-4/ <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the XOwner ❑Authorized Representative 0 Authorization to Apply form Attached <br />