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• —2.2.—coo-732.1—ii-vn—l• <br /> Application for Onsite For City Use Only: 1 Date Stamp: <br /> Wastewater Treatment System cl"f <br /> mA Date Received RIoNc402u 02 N2 <br /> •IIIIIII MARION COUNTY PUBLIC WORKS <br /> Received by ll V LED <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE AUG 2 <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt-11 <br /> BUILDIN Ty <br /> A # <br /> G INSPECTION <br /> www.co.roarion.or-us/PW/Buildindlispection ctivity <br /> A.Property Owner Information <br /> 1 <br /> &el Z ' <br /> rill S 3 perk Oeks 5 i- ne 1-.2..(zer Of (17303 St)?- 73'0 - lig <br /> Nam <br /> Mailing Address City,State,and Zip (Area code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tux Lot. Acreage or Lot Size <br /> Subdivision Name <br /> Lot Block <br /> 3to g0,Aaee- ,i- Al Del-co+ Or Cr73z-/Z <br /> Property Address City <br /> State Zip Code <br /> Directions ttr Property: <br /> C.Existing Facility!Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingie Family Residence rir Single Family Residence I:Public <br /> % 1 Name <br /> Number of Bedrooms Number ofBedrooms ID Private <br /> 0 Other 0 Other <br /> Weil,Spring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation Cl Renewal Permit nAuthorization Notice for:El amstruction'Permit 0 Permit Reinstatement Er Replacinga Dwelling <br /> R Repair Permit El Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 ES1Major 0 Minor D Existing System Evaluation 0 Personal Hardship <br /> Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 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*l'eqUit•ed fee and attachments are not included with this application.it will be returned to you as incomplete. <br /> Post 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 Connty,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 /> -‘)(ekit- Lot vex 94/9. . 8c3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number ' DEQ Lie.# (if aPplicable) <br /> •P• 0 ( Q F'f f CO k e 17 e K rat' 97367 <br /> Applicant's Mailing Address <br /> /6 636, / <br /> Signature 6r <br /> Date; CCB# (if applicable) <br /> Applicant is the Ej Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />