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Z Z —6o6/?-/- t, d/ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> -. = Wastewater Treatment System city of <br /> Date Received <br /> Ell <br /> MARION COUNTY PUBLIC WORKS Received by <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 /> www.co.mari n.or.us/PW/Buildin2lnspection Activity# S SS -22-Qo <br /> _y. e�4 V 1'3 i A.Property Owner Information <br /> k p -3-) (DUI J CtOS 24( Sf Ura 'r7 3U) 5 )3-430- 3333 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> OCA 21A/ 2 i 1) auitOD I- ZZ ie . <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> �^ <br /> 12J-1 /3 h,04 1,�,,4- In„ P k 1 u,2 ro E rQ- 0 q 1'39 2 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> E sting Facility: Prop sed Facility: Water Supply: <br /> Single Family Residence Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Private vV e 1 I <br /> ❑ Other 0 Other Well, Spring,Shared <br /> D.Type of Application <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> 1 ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ET Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other t)R A I t l(f tY I (- ❑ Connecting to an Existing System Never in Use <br /> ?evtr''-f' -- " r (over 5-yrs old) <br /> ,4JOT n�C /�� �11,)L_�I tic kemop G� [ Other-Please Specify <br /> Ifthe requiredf and attachments are not included with this application, it will be returned toyou as incomplete. <br /> 9 feePP P <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 /> Dep ent of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> av-em WItias 318-qFv- 3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 6k 5 2e st- Se /-ear 02_ q e730/ <br /> Appl'c 's Mailing Address --- <br /> ' -"--- aadAlifLiifti 7.--- /1- WIZ-- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />