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Date,Stapp: <br /> Application for Onsite Ear city Ilse Only: <br /> .-City of <br /> RECEVED <br /> _ -_,,, : Wastewater Treatment Date Received <br /> •System Received by MAY 23 2022 <br /> Zoning by <br /> Marion County Public'Works Fee 'MARIO N COUNTY <br /> Phone: (563)588-5147 BIlildifig IRSPOdtkia DiViSjPn ReceiPt# 13 ILDING INSPECTION <br /> Fax: (503)5$84948 55514E Court.St.,Ste.2260' <br /> wlyri,e9:marnn.er4is. <br /> PO Box 14500 • <br /> Salem,OR 97309-5036. Acifvity#• <br /> A.Property Owner Iriforinatitha <br /> Neksancir 1<rave1S 1163,0 S. P)oene:s . .,r-t-1 Rd,. wababur-ri oz otioli <br /> Name. :Milling A.ddren City,State;,and Zip (Arei Code)Pbone Number <br /> B,Legal Property Descrli:ition <br /> • $. -5 CKcjr. eS <br /> 05 w 1.96 00900 <br /> Legal Description TeX Lot Aereage'or Lot Size <br /> Subdivision Name Lot • Block <br /> T.) i <br /> --1 Pr1 1 <br /> Property Address: 11100 S.. BOOne_c VCYV1 Kow. WU:YU:NT-VI ibg , i._, . i. <br /> CD( <br /> Address .CiLj State Zip ct* <br /> Directions to Property; <br /> - . <br /> C.Rtitting Facility/Proposed Fl/it:,LWaterinformitiota <br /> Existing Facility: Proposed Facility: ft, Water Supply <br /> K Single Family Residence ' 1)1 Single ParniciResidence,.1, - P Public . <br /> 3 Name s':' <br /> Number of Bedrooms ,Number of Bedrooms K Private Wgi, 1. <br /> El Other Ef Other Well,Spring,.Shared <br /> D.Type of Application <br /> L_,,,.8ite Evaluation .0, Renewal Permit 0 -AuthoTion Noticefor <br /> El . <br /> 0:instruct' emit 1,t 0 Permit Reihataternent <br /> p.....„,tr eFt TO <br /> 0 1.epleeing.aThirelling <br /> i <br /> LIWRe.. ermit Wi i 0 Permit Transfer 0.TheAdditon of One or More Bedrooms <br /> 0 i7erseceiRard:Sbip <br /> • AMajor 0-Minor 0 Existing System Evaluation 0 Temporary Rousing <br /> n Permit , 0 Record Review 1:1 Connecting to an.Existing System Never in Use(over5-yr.a old) <br /> lit Major Q IA inc.'. 0 Other III Other-Piese Speci <br /> If the requiredfeq andattachment.s are not included.Oih this upplication, it will be returned to you aS-incOmplete. <br /> Post the orange card at the chtrancetothe property, #Iais'thniestlioles. <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 /> American ty) S14„e 5b3-Eci-"Itp00 3S:311 ( <br /> , Applicant'S-Name-Please Print Legibly Applicant'a Phone Number DEQ Lie.li-(if applicable) <br /> ;• <br /> 3in i S S. likAN ..e9ila Mtlta I't 0, OR-ont.2 <br /> pn <br /> Ap . MailingAddre.s 's <br /> p <br /> Sigriatute•to/ Date CCI311(if applicable). <br /> • <br /> Applicant is the 0 Owner 4AuthorizectRepresentative. i(AnthorizatiOn,to Apply form Attached <br /> Q FORMSSEPTIC15-0 I I2009 Appncet.,..10c Page 1 or 2 <br /> . . <br /> • <br />