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4, 06-7 / 61 <br /> Application for Onsite <br /> , '�a„ For City Use Only: ��Date Stamp: <br /> � �Y <br /> - C ___....)9) <br /> — ;_ Wastewater Treatment System city of <br /> Date Received <br /> nom ---- <br /> MARION COUNTY PUBLIC WORKS Received by ` ce) <br /> Hil <br /> BUILDING INSPECTION DIVISION Zoning by 0 <br /> 5155 Silverton Rd NE Fee ` : j- <br /> ii: <br /> Salem OR 97305 CO ) - <br /> (503)588-5147 Fax(503)588-7948 Receipt# -D 0 tv <br /> co <br /> www.co.marion.onus/PW/Buildinelnspection Activity#_ : <br /> Era <br /> 2 0 16,51...._,; f r i_ ” ,t Pro ert ,Owner inform,Ip44 , <br /> Cd1,G 1A - Zo Co. P.o. N 8 S�.P,.f 9737 c 3-3FS3 3 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> E ' ..,- .. .. 7,:;, ,,, 3 �Bs.Le al Propeh Description ,„, . , t .. <br /> IC 15 t 7) vs7 z,d ©i7®o 5 . `U <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 5-133 Keene._ Rd AJC icerve0.5 OE 9 p <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> 1 .7,S 1-1 East- 0 3,-e ' •• em 06 r ' S -'� p • t s*t1.- 'd <br /> -...x Mri-,.,:. ..ga „-: O„Bxishng)*a lA /Propoked`Factlxry(Wa er4tifoririahon , ...U .0 t ._28, F, <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ❑ Single Family Residence OPublic <br /> 5— Name <br /> Number of Bedrooms Number of Bedrooms Private �t 1 el <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> E s AE ' Ek5 ^. E D T e ofA ltcatlonv2 : <br /> S Y <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> S Re air Permit 11 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> la Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor D Other ❑ 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 /> (HO 52 Cttcej 5t 3 3 3 73 / 3 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Fr 50X vl 51,PC14,1 o 97 137 <br /> Appli is Mailing A. - s <br /> i �.. . ( q i q <br /> "`ignature Date: CCB# (if applicable) <br /> Applicant is the kOwner 0 Authorized Representative 0 Authorization to Apply form Attached <br />