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/ 4 - oo534 / &- IZ 11 <br /> Application for Onsite par c; xoa,y: arm: <br /> Wastewater Treatment System city of 2iZ a <br /> c <br /> Dale Received Z 1-+ = <br /> MARION COUNTY PUBLIC WORKS Received by �O Ga = <br /> BUILDING INSPECTION DIVISION Zoning by mC 0 <br /> m <br /> 5155 Silverton Rd NEFee OZ <br /> Salem OR 97305 Recei t# 0 <br /> (503)588-5147 Fax(503)588-7948 p - - Z <br /> www.co.Marion.or.us/PW/Buildinglnspectiop Activity (t J <br /> A.Property Owner Information <br /> (k,,,,,_[ l(r,..,..tvs-i....... 2'?6 rIctec y c..SF $' 'e —, OIC 41911 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> C'iawc:,tntr t,.t.l..t- I;).e ri S,.tsrin,rt- 0 244-4 030 O3500 a.., U rro e.,'S <br /> Legal Description Tax Lot Acreage or Lot Size} <br /> Subdivicion Name Lot Block <br /> -1,257 ✓idue (t Rd Sr ScCer Ctrl 9-1317 <br /> Property Address J 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 ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Gsh Private tilt I,' <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> a Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> liCI 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 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 /> Ur <br /> S41.0 f °nisi Lu Scri-el y -ykrcr 2olt:, 7 31s 4e• <br /> Applic>Mt's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> R3 &qc I 2Scl 54cavini x/12 '738/ <br /> Applicant's din Add _ <br /> y{yaa 7- i'3-/-7 2oI 6 es3 <br /> ffiv� Date: CCB 14 (if applicable) <br /> Applicant is the❑Owner -{t Luthorized Representative authorization to Apply form Attached <br />