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Application for Onsite For(sty Use Only: Date Stamp: <br /> II Oa4li <br /> - ;= Wastewater Treatment System city of <br /> I-- <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> _;�1. A.Property Owner Information <br /> `Da,3ld T Kc9 31-741 5,vv_Sauafe Q(1 Stu/rid-6th oil g737T 0E13 2291 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> n9P:tP 01icD J'7 aoPe5 , <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1t -191-1 t)3Dit AM ./P:- <br /> Lu 611-5 -6- <br /> Property Address City State Zip Code <br /> Directions to Property:NIVI� 071-H-Wy 22 E 4v L ems' L.e 41--0,rn on No-✓t1,7 a i d , Gv it <br /> Lt,-F+ -"on 00 Jui_l_n. Prov. Pc{ 3 p to -FDP DrivLwa js on-1-1;t1 rI �►�-o <br /> te <br /> (.43:I:will S * zo x5-0 vJ0o6.,24,1 butl t 9 wigs yun ern rig 6 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence ❑ Single Family Residence ['Public <br /> `,7 Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> 0 Other 0 Other Wel Spring, Shared <br /> D. Type of Application <br /> [Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit El Record Review ❑ Temporary Housing <br /> El Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> O 1cfT Rcti 5-OD 04f3 97c <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3 f l`fl S v✓�c,V au Rc(, 5furi clan 012 97378' <br /> Applicant's Mailing Address <br /> /AV/ 24 �1,2�� <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the L�Owner El Authorized Representative ❑Authorization to Apply form Attached <br /> PPP PP Y <br /> tl <br />