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. cz- bloQ\3eiz‘ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> • -440$0"'"I`";: Wastewater Treatment System City of _ RECEPV_Eri) <br /> iniimmig, _ Date Received <br /> : ... <br /> MEN b <br /> MARION COUNTY PUBLIC WORKS Received y <br /> 20,8 L. <br /> BUILDING INSPECTION DIVISION Zoning by _ DEC 1 <br /> Mr' <br /> 5155 Silverton Rd NE Fee MARION OU \I <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# BU _DING INSPECTION <br /> Activity# <br /> '', vi.ww.co.marion.oraistPW/Buildio#Inspection <br /> - A,Property Owner Information <br /> ; -- <br /> 1.2:2,Y1 i In Ck 'Pe) IC)01.... 2..153.3- f'l IAA-Um 0 R. 411 5(.°)15' (31 I. gag - nu 9 <br /> Name ,,,,I Mailing Address City,State,and Zip (Area Code)Phone# <br /> •Legal Property Description <br /> 046 2.1A-1 3(.31-TA)°3°° 0 300 JD <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> _oil_ <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.,ExiSting Facility I Proposed Facility/Water Information ;.,..,t'• -..- , , , - ' <br /> EXisting,Facility: Proposed Facility: Water Supply: <br /> 0Single Family Residence , 'Single Family Residence 0Publie <br /> 1 btAr.04.1 nA Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other 0 Other Well,Spring,Shared <br /> 1) Type of Application <br /> 0 he Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ° Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 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 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 1 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 purpoF of this application. <br /> _ / )Ot- , e*I-ctxtitt-Ait)ex LI-L <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie,# (if applicable) <br /> i Lit I D 5- 5 sow),Lc rd Of, iszi_edv og_ 97a/Applic. is Mailing Address <br /> A 12 .17- ZoZo 22.5-11c* <br /> si, .tUre Date; CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative Authorization to Apply form Attached <br />