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Application plication for Onsite <br /> .alt iy,i,` For City Use Only: Date Stamp: <br /> _ v Wastewater Treatment System City of <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/PW/BuildingInspection Activity# <br /> A.Property Owner Information <br /> Page I brn chka (.1430 ( IJ'6 641'1 Ave \kmcouve. -I WA 9%625 3(00-521—(o(oog <br /> Name Mailing Address City. State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> PO•A t&611: / vU 1782.003C ol©oo i.St <br /> Legal Description Tax Lot Acreage or Lot Size <br /> ISIZFX Oak Nal— Farri LOW - — 0211 00 ZI o <br /> Subdivision Name Lot Block <br /> (os91 , aavt.on 5.r. Sed tWI Olt 9731-} <br /> Property Address City State Zip Code <br /> Directions to Property: O0(-kk cll. 4 reek' l ekWeei1 654 I 0.Kd 6,( S i &rim ) St S6 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence X Single Family Residence ❑Public <br /> ifName <br /> Number of Bedrooms Number of Bedrooms 14 Private <br /> ❑ Other ❑ Other - Spring. Shared <br /> D.Type of,Application <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> iili Construction Permit ❑ Permit Reinstatement ❑ Replacing 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 lest 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 /> l-x 9 atm/A6 <br /> t m/A6 Rowe Solalioons, (-Lc -gg9-o538 zgc6tk <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P,0. BOK 2 \ �(),oh 1,Ayn I 0 q.1o1 <br /> Applicant's Mailing Address <br /> (ill5 /2A))61 21gCl0g <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 111 Authorization to Apply fonn Attached <br />