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l5-OO8rJ3(o-4t rN <br /> Application for Onsite FmQQU.eOSy: ,: <br /> — Wastewater Treatment System DCate Received <br /> 1(2 n i� n <br /> Dity of ! _ , ILLLU� <br /> MARION COUNTY PUBLIC WORKS Received� '�' OCT 31 <br /> BUILDING INSPECTION DIVISION Zoning by 020U19 <br /> 5155Silverton Rd NE Fee PvUli;lf_-?d;l COUNTY <br /> Salem OR 97305 ceiptA 8LfPLDING 6Vyp�CTlO <br /> (503)555.5147 Fax(503)58Re <br /> 8-7948 Re eipty# N <br /> Av <br /> www.co.nuirion.or.us/PW/13uildinelnsoection <br /> A.Property Owner Information <br /> 5fl.o. .UA) /312.VM©[4V6-d Po 0 oe, i im.spuhicacseesizat AOR- 5o3677 ($Bt <br /> Name Mailing Address City,State,and Zip cr78pr-/ (Area Code)Pin# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> i3 no LL,t5T>sae-/r4 KU)R-0 P.-x4 pfz 97 e.oZ, <br /> Property Address City State Zip Cade <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: P. Facility: Water Supply: <br /> 0 Single F 'y Reece Single Family Residence ❑Public Paste- GO-4a- StrtatiallS <br /> Z. Name ' 4 "€4— <br /> N of Bedrooms Number of Bedrooms 0 Private <br /> e,. 0 Other Well,Spring Shared <br /> ' D.Type of Application <br /> \I(/ ite • <br /> Evaluation 0 Renewal Permit Application <br /> ization Notice for. <br /> �f: C• 'bostmction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> • R• epair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> DJ Major 0 Minor [ Existing System Evaluation 0 Personal Hardship <br /> ❑ Attention Permit [ Record Review 0 Temporary Housing <br /> O Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other-Please Specify <br /> If the requiredjee and attachments are not included with this application,it will be returned to you as incomplete. <br /> Post the orange card at the enuarce to the property. Flag the test holes. <br /> By my signature,I certify that the information I have furnished is correct,and hereby gam 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 /> SiktAL[9A) B12v14t3+4t>v-1 Baa 577-)S€'-{ <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.it (if applicable) <br /> 1�0 1549,L 1 ,i Se.41bfKe'c2.€K OK ci7e9oLi <br /> 7plicant's , <br /> 64 <br /> 3i"puma Date: CCB# (if applicable) <br /> Applicant is the❑Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />