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2 <br /> z -o O S3ZO - itmr <br /> W41 ,,F,E3J( AppliMNcation for Onsite For City Use Only: �s <br /> Wastewater Treatment System City of . Do ` DR <br /> Received 0 Z <br /> MARION COUNTY PUBLIC WORKS Received by • — C n <br /> Z F-► O <br /> BUILDING INSPECTION DIVISION Zoning by • C` C71 <br /> 5155 Silverton Rd NE Fee • �. o <br /> Salem OR 97305 Receipt E Iv - N <br /> (503)588-5147 Fax(503)588-7948 p . ill <br /> www.co.marion.or.us/PWBuildinalnspection Activi � '' <br /> A.Property Owner Information <br /> t)A Al IJQ alb a 01 imocso D — ,ql of Os- ?730( . 3-SIO-62yf <br /> Name Mailing Addres City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> oe Z w 2y Le Z9O0 , (pc, <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> gso7 fie.-vivCo m ?72/7 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ix Private loV EyL.L— <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> RI air Permit ElPermit Transfer ElThe Addition of One or More Bedrooms <br /> Rea Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ 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 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 /> Z0Cci0)4g2 S0.3-77/— GS7r 367V7 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 677( Prz"r z_ QO. S� A a oti s r•i i PT- 40,E 9Vs?Z6— <br /> Applicant's Mailing Address <br /> 6 /y/zz 2�.?7 <br /> Signature Dat CCB# (if applicable) <br /> Applicant is the❑Owner KLA.uthorized Representative ❑Authorization to Apply form Attached <br />