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2A, ,e 7 0- 69 o6 - ,,&m ..., n / <br /> � Application for Onsite C Date' C3 <br /> ,„ ,�,.�, pp For City Use Only: <br /> Ril <br /> �-4•; Wastewater Treatment System City of 5 <br /> Film <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by Zo0 r 0 <br /> O Nil <br /> BUILDING INSPECTION DIVISION Zoning by Z 0 <br /> 5155 Silverton Rd NE Fee 10 0 0 <br /> Salem OR 97305 M C N <br /> (503)588-5147 Fax(503)588-7948 Receipt# C)Z TH <br /> www.co.marion.or.us/PWlBuildinglnspection Activity# '� <br /> 0 EN <br /> A.Property Owner Information <br /> 9I7 Kl g,0DC 4' f (A/. Locr 5f- Sv loe) or. 9 3a 3 97/-375--9/i3 <br /> Name Mailing Address City, State, and Zip (Area Code)Phone# <br /> B. Legal Property Description . <br /> O, 3 /1 Z3o/oo� c .-l <br /> Legal Description Tax Lot crea or Lot Size <br /> Subdivision Name Lot Block <br /> /02,2 /tforik Far`K 4/V S E 1,/o✓is ,r. I'35 <br /> Property Address City State Zip n/' Codet <br /> Directions to Property:/5 ,17 �2.I j4� /l/ <br /> on -Fr,/l< Ip II irnieS 5 71etti <br /> r/ /Y'or- rii'k .1.*,T -t 7z i r,i%e a4 e, Ge 5i e9`74CRc ,o/• <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence jg.Single Family Residence ❑Public <br /> ., 3 Name <br /> Nuit6er of Bedrooms Number of Bedrooms ig..Private WLL. <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application.,. , <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authr-iition Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> 4 Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> \ ❑ Major it Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration '-rmit ❑ Record Review ❑ Temporary Housing <br /> ❑ Ma'•r ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> - (over 5-yrs old) <br /> A� /1 <br /> 5q1; 4 on El Other—Please Specify <br /> If the reegi.di ed fee and attachments are not included with this application, it will be returned to you as incomp te. <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 gran' a ' n j�oon y,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the above described prope tl sole purpose of this application. <br /> q "1/ - <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> Signature Date: CCB # (if applicable) <br /> Applicant is the ❑ Owner ;►:! Authorized Representative ❑Authorization to Apply form Attached <br />