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c_)5S1\ - cr\--b\S Q QST <br /> Application for Onsite g„eb a, wa�.n <br /> Wastewater Treatment System c” °` <br /> M . DateReceived _NEC -F NEI <br /> I <br /> MARION COUNTY PUBLIC WORKS Received by ivied <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Stherton Rd NE Fee <br /> Salem OR 97305 <br /> OCT Q5 2U11 <br /> (503)508-M47 Fax(503)580-7948 Receipt 4_� "ej� <br /> awn.co.nmrion.or.oWPW/Buitdinginspection Activity MARION COUNTY <br /> A Property Owner Information <br /> w BUILDING INSPECTION <br /> Recto S_Ixtos 22015 Camellia Ave NE Aurora.OR 97002 (503)287-7743 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone it <br /> ' - B Logal lNaw"i Description <br /> LLODIA ILO LOQ `3CY'� <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 0etc &-ceA- 'C5\CNICC IA-2_ 10 6 <br /> Subdivision Name Lot Block <br /> 22015 Camellia Ave NE Aurora OR 97002 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Fee/My I Proposed',acuity:f Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence D Single Family Residence iitPubitc <br /> It 2 Name <br /> Number of Bedrooms Number of Bedrooms W Pi-note <br /> ❑ Other 0 Other Well,Spring Shared.. <br /> D;Type ufApphcation ':. <br /> ❑ Site Evaluation ❑ Renewal Permit QAuthorizatko Notice ton <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> J- Repair Pemut 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> O Major cjir Minor ❑ Existing System Evaluation ❑ Petsonal I Iardahip <br /> O Alteration Permit ❑ Record Renew 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-311's old) <br /> ❑ Other-Please Specify <br /> Ifrhe requiredfre 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 comet,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 /> Chris Clasen!Lil" Stinky Environmental Service 38231 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ lac_a (If applicable) <br /> 19631 Kolar Dr. Oregon City, OR 97045 <br /> Applicant's Mailing Address <br /> 'A C1 t rJl 189693 <br /> Signature Ir. Date: CCB 4 (if applicable) <br /> Applicant is the 0 Owner ® Authorized Representative N Authorization to Apply form Attached <br />