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ZZ �02 /06 - P(4 <br /> , i <br /> 4 Application for Onsite For City Use Only: ✓ df <br /> q a-- Wastewater Treatment System City of r- DMI <br /> Date Received z = <br /> 1111111 MARION COUNTY PUBLIC WORKS Received by s7 Oz C <br /> BUILDING INSPECTION DIVISION Zoning by 4- O CD M <br /> 5155 Silverton Rd NE 71 sv <br /> Salem OR 97305 Fee n C ci <br /> (503)588-5147 Fax(503)588-7948 ReceActivity# -. <br /> rEl ww.co.marion.or.us/PWBuildingInspection Z <br /> A.Property Owner Information <br /> me.,.kw. a-7► 1/Uf4ai/,,, G SS Srvalligh-1 air:— J �'�— '?73Q5— <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> e 7� W l3 ao ciao 4ciaa /4 7 Z7 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> - 7s3-- a&1 the4J ala NE aq__ 9730s`e <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility I Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms K.Private IAJ_..LI <br /> ❑ Other [X Other VA,e2d( 1.& L.. 12.4-121.1a evt5 Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> (,0' Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ■ Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major El Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 1,1)0 <br /> (1 *' <br /> ©,- -,(9/p-"— ❑ Other—Please Specify <br /> If the required fee and attachments are not included whis 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 /> Departmentpa of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> `rjao E_ zc,cc-i nl c 5-03— ,`?/—r:S-7T 3 6 7V 7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 277/ Pit _ (2..�. 1E_ AKrijdiGe.c 0.79_ %7 2s _ <br /> Applicant's Mailing Address <br /> 40.1 - ,_7/7/e 2__ P2 Of 7 <br /> Signature J Date: CCB# (ifalicable) <br /> I <br /> Applicant is the❑Owner Authorized Representative ❑Authorization to Apply form Attached <br />