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EXP1RE , <br /> z /- &ov)-2 2_ , t'A' m 7 <br /> .. Application for OnsiteCO 0 <br /> '°4 For City Use Only: DP <br /> - � Wastewater Treatment System city of 0 D T. <br /> INII Date Received n 0 <br /> MARION COUNTY PUBLIC WORKS Received by 0 -< <br /> BUILDING INSPECTION DIVISION Zoning by Z O M <br /> 5155 Silverton Rd NE Fee (f)0 0) <br /> Salem OR 97305 13 0 o <br /> (503)588-5147 Fax(503)588 7948 Receipt# M C <br /> Activity# 0 Z M <br /> . A.Property Owner Information Z (— Li <br /> ./. / A' 4o/clS 'Yens scilar .a2 c n o, gags- (503)5/0 - 9m <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> friso Aec.itl7 i339 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> I53 S 114- ,7 r;�'J c;ir 4tws l7 p 3.5p <br /> roperty Address Ci State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> K8ingle Family Residence ❑ Single Family Residence ❑Public _. <br /> 2- Name / <br /> Number of Bedrooms Number of Bedrooms ,Private -) <br /> 0 Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> Er Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> fg Major ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 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 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 /> Lone Pine Corner Septics Inc. 503-873-7157 37003 R-I-100 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> A licant's Mailing ddress <br /> ‘,; S—60 2 ) 177063 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />