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_. . <br /> . <br /> ' <br /> ` <br /> b- bDs k no <br /> \ <br /> tx� uApplication for Onsite For CitjUse Only: <br /> --= Wastewater Treatment System cityof <br /> allA4TlO COUNTY PUBLIC wollcs Date Received <br /> Received by Dille SlnIu : <br /> _ EJEBV -F <br /> ILi NOV 18 2020 <br /> BUILDING misrECTIONDIVISION Zoning by <br /> 5155,Silverton Rd N1 <br /> Salem OR 97305 Fee ION COUNTY <br /> (503)588-5147. Fax(503)588-7948 Receipt if BL ILDING INSPECTION <br /> www.co.tnarion.ar.urfPWf[inildingin spcetfort Activity ii <br /> I. • . A.Pzop Owner information_ ...-. ..... -- --........ ... .: <br /> _ _.__._ qty_ __ �__� , — <br /> t-e•1 k .t V1c-x-6(1 1-g)56'1 i'Zq(A/'&evil-1k Cr ? s �1//g yes <br /> Name � � 1 y'Y'� cf,'� �7✓ �i 7�OQ"`t yes--08-e3' <br /> J.?............... . .... _ Mailing .ddress City,State and Zip (Agee Code)Phone <br /> YV 1 Ei SY • -Ce <br /> Legal Oescrrip on Tax Lot Acreage or Lot Size <br /> W'e 5 4"-CI CI 4"C._ t q Q Yl l'. 7-0 <br /> SubdivisionNdme Lot Block <br /> IP a W • �.- YI-r 'rq( rS -1— &cl+-e 0R x'173 We • - <br /> -Property Address City State Zip Code <br /> Directions to Property: <br /> • <br /> : .......... .. ......: : '^ ...... 3tingFa ility f rmpotedF iliiy i W_....._.......-._.._........._.' •. ......:.. .. -.,: .....:....... ..-. <br /> • C. ,ris c' ae' iter 7noi ina[ion <br /> Existing Facility: Proposed Facility: Water Supply: )) -- � <br /> t�'llSingle ilyResidence Single Family Residence [ Public (C(7't U "c -1"-(}' <br /> / <br /> l ,.., 3 Name <br /> • <br /> Number of Bedrooms NumberOf$edrooms U Private <br /> ❑ Other ❑ Other _ _ Well Spring, <br /> 1 : % -._.:;_c....,'.....:. ....... • D.Type of kpplicntron - :._._. ._: -T • • 3 <br /> ❑ Site Evaluation 0 Renewal Permit Oillthorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement . Replacing a Dwelling • _ <br /> ❑ RAmir Permit 0 Permit TYansfer 0 The Addition of One or More Bedrooms <br /> ( I Major [❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Penult ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 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 sigunture,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of EnviranrnentaI Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Vi L+D(1 611 L4(3011 71,0-ggS=o33 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> 7-LI V/ ' ,-eY4-al i s+ Octt C1R 973`/( <br /> •pp.ant's Mailing A.dress <br /> / <br /> gnature Date: • CCB 11 (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:IFORMS151rPTIC4S-01 O11S1TE APPL SGPT 2018.DOCX Rev 1115,3115 <br /> 6'd 9909L69909 sale 03O 40 d99:t0 OZ 9l.ADN <br />