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EXPIRED ickt-005 ia'-1--i3rn-\- <br /> Application for Onsite <br /> "mig.,.,� i'L' For City Use Only: Date Stamp: <br /> ---. Wastewater Treatment System City of - C O n <br /> Date Received D V � <br /> NIARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by _ JUL 1 1 2019 J <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www_co.marion.or.us/PW/Buildin2InsQection Acti'iIV# <br /> A.Property Owner Information <br /> Lto Diibgk MI5 R►YcrilcV e .i LA in gpt44I oj' 77 54l-, 77I-895.5 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> 0? IE J{ D C B.Legal Propel Description /r/7 <br /> Legal Description`� Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> i/g15- Rig(Afifeyi Lk, 4_14-filiftqa+, o/f <br /> Property Address City ep ) State Zip Code <br /> Directions to Property: Njvy -2. /�C Al />r 5 E/�'�/Pl*lit✓ 4,Vta f / it 5e <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Prop ed Facility: Water Supply: <br /> Ingle Family Residence Single Family Residence ❑Public <br /> 2 Z Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> 0 Other ElOther W , Spring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> 0epair Permit <br /> . ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 ajor ❑ Minor 0 Existing System Evaluation 0 Personal Hardship <br /> Alt tion Permit <br /> ❑ Record Review 0 Temporary Housing <br /> Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> 1 (over 5-yrs old) <br /> • Na lraSktf (4k (Lq�,fl I AJ 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 /> Jess CZ; . 5'o3-q3z--z4/Di 3‘ 3z3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic. u (if applicable) <br /> -L470;1 Prki'4. 369d I<&$1 m:v 5 5c/el OR CM317 <br /> Applicants ling Address <br /> a 03 / 50-/7f <br /> Si a Date: CCB# (if applicable) <br /> Applicant is the❑ Owner Authorized Representative Authorization to Apply form Attached <br /> DS t E luL D D_l <br />