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i REC'D MAR 2 6 2013 <br /> Application for Onsite ForC;ryoseoaly: p �Q D <br /> City of <br /> Wastewater Treatment System A `�/M� 013 <br /> ® Date Received LA <br /> MARION COUNTY PUBLIC WORKS Received by ARION COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by BUILDING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem47FaxOR 05588-7948 Receipta /3.- 0/�tS <br /> (503)588-5arson. r. Fax(503) ingInspe Activity# <br /> w.co.marion.onus/P WBuildinglnspection <br /> At--1-704> fii5olz73 <br /> A.Property Owner Information <br /> Mani_ ANelaiSCT\ 2151y „y�Ge.6Nut. Sft mo X3- 4/3 3313 <br /> Name Mailing Address • f City, State,and Zip , (Area Code)Phone# <br /> B.Legal Description <br /> E-f l) -C-0:44-11.,..4 ' Legal.Property <br /> 013©e 24 , is Auk-e.,. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 21671 ct .pe—A3 aftali.f il• C Sk. aj 0 IZ U 1 i 5. <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 0 Single Family Residence DPublic <br /> ` —Ibwr �/ Name <br /> Number of Bedrooms Number of Bedrooms V�Private lAkilik <br /> O Other 0 Other Well, Spring, Shared <br /> D.Type of App on <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> XRepair Permita ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major lM 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 /> 1 ANektsen 593 n-72003 <br /> Applicant's Name—Please Print egibly/ Applicant's Phone Number DEQ Lic.# (if applicable) �7, 1 T <br /> 2 s7�( a p C 1 1..1s NE St. P0.wit ® pI 3' <br /> Applicant's Mailing Address <br /> __ /14C/ 2/111,3 <br /> Signature / Date: CCB it (if applicable) <br /> Applicant is the Owner <br /> 0 Authorized Representative 5 Authorization to Apply form Attached <br />