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<br /> iii...... asAtewPP al ticear e°ntnssi ytestein (-----zr::ex:„ w at City the Only: ‘III •,.. • ,./
<br /> i/VISpr-
<br /> c tioN
<br /> Date Received
<br /> MARION COUNTY PUBLIC WO ' Receiv ed by BUTI,DING LNSPECTION DIVISIONS ........_______
<br /> SISS Silverton Rd NE Zoning by
<br /> Salem OR MOS Fce
<br /> (503)5n-5147 Fax(503)S8S-7948 Receipt A
<br /> i yo-sv,_„_.ei),n_iarladmr_.usfrlY/Apittlingislpeetfa Activity ii-----
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<br /> A.Property Owner Information
<br /> , NuoCA '-'4--- ---- ------4-4-11"1----- -54.1,0441._Cie,__51, ---
<br /> Mailing Address
<br /> City,State,and Zip (Area CO(
<br /> B.Legal Property Description
<br /> I Legal Dcscriptiot --- Tax.t:jr-------- ----------
<br /> Acmage or Lot Size
<br /> I.;i----------
<br /> Block
<br /> . J
<br /> ity
<br /> 11.,‘ Directions to Property: State Zip Co
<br /> )'-
<br /> C.llitisting Facility/Proposed Facility!Water Information
<br /> Existir)g-racillty:
<br /> Proposed Polity: Woter Supply:
<br /> I",:i: tilingle Family Residence
<br /> 14<j*Randy Residence OPublic
<br /> ,4 ______L____. Name
<br /> Nun12 of Bedrooms Number or Bedrooms reidvate C.J,0
<br /> i iI 0 Other 0 Other
<br /> Well,Spring,S
<br /> I I D.Type of Application
<br /> i 4 CI Site Evaluation 0 Renewal Permit °Authorization Notice for
<br /> _,O Construction Permit 0 Permit Reinstatement El Replacing a Dwelling
<br /> 1;mi/12_9*P:emit a IPermit Transfer 0 The Addition()Mite or More Bede
<br /> If ,U Major a Minor E4 .47`,. ting System Evaluation 0 Personal Hardship
<br /> ,.."
<br /> 0 Alteration Penult II Record Review 0 Temporary Housing
<br /> 0 Major 0 Minor 0 Other 0 Cormecting to an Existing System I
<br /> !i
<br /> (over 5-yrs old)
<br /> El Other-Please Specify
<br /> lithe required*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 eertilY that the triton-nation I have furnished is correct,and hereby grant Marion County,authorized
<br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of th
<br /> App
<br /> cSt,, 1/11144,4,t i,,bly Applicant's Phone Number
<br /> DET,Lic.# (if applicable)
<br /> rcant's Name-Please "
<br /> A,,,,...s t L, cv-
<br /> Applicant's Mailing Address
<br /> CCB L# (ilapplicablc)
<br /> Da .
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