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moo^ 0 W-- fl: LT r--- --ig <br /> Application for Onsite ', St li <br /> For CityUse Only: <br /> _; 4 Wastewater Treatment System city of 0 <br /> OMDate Received Z f-" FIRMARION COUNTY PUBLIC WORKS Received by Nam'u <br /> BUILDING INSPECTION DIVISION Zoning by M C fa" 5155 Silverton Rd NE Fee _ <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> _ M 3 3'3Iu3 ,. A.Poi: ty f U ITIfOiXtlaxxOil._.:k:.'.3 _... F..___.,.,I <br /> EEEU <br /> R )Y\ <br /> (?\ s _ ��lc���'1 0:C3) <br /> Name MailingAddress City,State,and Zip rea Code)Phone# <br /> a B Zegal Pra scriiption "'' <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 11 C (03 ` q&Do& C3rdt Lolls M c17 6R <br /> ' Property Address City State ,_ Zip Code <br /> Directions to Property: <br /> _ C ExistingFacihty!'Eroposed.Facilityl Water formation <br /> Existing Facility: Proposed Facility: -Re p(ate/nex Water Supply: , <br /> ['Single Family Residence Al Single Family Residence ❑Public <br /> 0 'q Name <br /> Number of Bedrooms umber of Bedrooms Ki Private Sh/21,r a <br /> 0 Other ❑ Other Well,Spring,Shared . <br /> 9 l3 ' D_Typo of Application <br /> El Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> 1I1 Repair Permit ❑ Permit Transfer , ❑ The Addition of One or More Bedrooms <br /> VI Major El Minor El Existing System Evaluation El Personal Hardship <br /> El Alteration Permit 0 Record Review ❑ Temporary Housing' <br /> El Major El Minor El Other ' El 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 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 /> AAa AV)) 7 di` E e( 7i &(q9- e <br /> Applicant's Name—Please Print Legibly . Ap' leant' hone Number DEQ Lic.# (if applicable) <br /> -PP, `Bw 17 .7 Lio s ®k 1?735e <br /> A li is Mailing Address <br /> frAlmi /693 9' <br /> gnature Date: CCB# (if applicable) <br /> Applicant is the El Owner 741.uthorized Representative El Authorization to Apply form Attached <br />