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,.:„, . Application for Qnsite For City Use Only: Date Stamp: <br /> 1 mil.... ..=� Wastewater Treatment System City of RECEIVE <br /> Dat <br /> e e Received <br /> MARION COUNTY PUBLIC WORKS Received by MAY 0 81014 <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 /> #r r :il' ; ; : -• Activity <br /> t f !tsSije.t75 , : ,<, �-a->-.>-;. ty <br /> A.Property Owner Information <br /> /0:I f/40/J5 li'ms s ,,., ,ccie,pg oe 573as- (saps/0-99 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> d93f da®eceigiO Roc. Y3s! <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 7G3-,ark.7 6~dr C'f h. ons a F7 .5F- <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> j ingle Family Residence 0 Single Family Residence ❑Public <br /> GC= Name <br /> Number of Bedrooms Number of Bedrooms %Private 4-) <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> L-_, Site Evaluation 0 Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement . 0 Replacing a Dwelling <br /> E Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> Vg Major 0 Minor 0 Existing System Evaluation 0 Personal-lordship <br /> ❑ Alteration Permit 0 Record Review <br /> El Major 0 Minor 0 Other ❑ Temporary Housing <br /> 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ 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 Lie.# (if applicable) <br /> 8778 Cascade Hwy NE Silverton, OR 97381 <br /> licant's Mailingddress <br /> 1 .fir <br /> 64 4,j 177063 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner • 0 Authorized Representative ❑Authorization to Apply form Attached <br />