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� � ia <br /> for On site <br /> .. Application O s For Use Onl : p: <br /> � ��,v,� City y <br /> Wastewater Treatment System City of JUN 2 6 H17 L) <br /> Date Received MARION COUNTY111111/ �� <br /> MARION COUNTY PUBLIC WORKS Received by BUILDING INSPECTION <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# <br /> www.co.marion.orus/PWBuildinglnspection <br /> ya ip 1 . ' 7158 747teflatisII M T� %:g.,,Tis s ^.R'' <br /> DZsi,Q fi L Ma\\\M" <br /> Name MailingAddress City,State,and Zip (Area Code)Phone# <br /> ;'F �"- .._ 'Ta.� f 3' "- aT .; c w..n '+ tides .� " 1.E.-r j {'r;-� �^ '1 <br /> r _. t:.1. g;�;: .�7espn ono -r,>,- ", _+ _ a % <br /> - nn,wvoc7 Oct€o3i 2�c.Ooo3p3 S <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> SOsba l—\. <V\3OOC 0r 9412. __ q�')�� ) <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> iriii sl�ct tnDPo ger,lifikErl er n igati =r i <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ogle Family Residence I Single Family Residence ['Public/ Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring, Shared <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement ❑ RepIacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> O Major 0 Minor 0 Other 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 10 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 /> �� 1NC, . 3-6112—SVOL. <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number / DEQ Lic.# (if applicable) <br /> P. o , e;o,c 9q3 c - \ e „-t otC_ 917coJ <br /> Ap. 'cant's Mailing Address J <br /> '4. (P.02(0- 11 1 r1I (ON <br /> 1� <br /> Si ture I Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Representative (Authorization to Apply form Attached <br />