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i€ c�aa- <br /> • Application for OnsiteCityOnly: Date <br /> - ;,i w,4� • <br /> For Use Stamp: <br /> City of <br /> ' — N � .Wastewater Treatment System U -V- '= <br /> "` Date Received - <br /> MARION COUNTY PUBLIC WORKS Received by q ..2 <br /> ' . BUILDING INSPECTION DIVISION . Zoning by MAR 2 8 201 <br /> 5155.Silverton Rd NE Fee <br /> COUNTY <br /> Salem OR 97305 Receipt# BUILDINGINS PELT ON <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> _i __. _..,L_z__.._ A Property OwnerInfprmaton E! <br /> v - x-4 is GBerber x145l geiit�4 kd u �.':Os/--- 739Z 505 SS'D /a07 <br /> Name Mailing Address I City,State,and Zip .- (Area Code)Phone# <br /> t 1 B Legal Property Description; �, >�w <br /> C>f3 3 t. Z(, ,)DN %CC Z , y , • <br /> • Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot .Block <br /> g 1 6 teat4/ecreekr 'r5E . SO// 1'1. Or V?JJ7 • <br /> PropertyAddress . City State Zip Code <br /> Directions to Property: <br /> C Extstmgllacthtyr/ProposedFactlrty/WaterInformatton <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence Bingle Family Residence ❑Public <br /> 5( Name "� <br /> • Number of Bedrooms Number of Bedrooms Private - (//644 <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ..r ]L,. !:; Type of Application ` ,.... <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ®'Construction Permit • ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> • ❑ Alteration Permit • ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ 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 uality,permission to enter onto the above described property for the sole purpose of this application. <br /> r� /i„,,, .., f y9. / :meters y <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ,...eaves 0/5-e oto'/z c i yr 9?..ie) 7 <br /> Applicant's M.iling Address <br /> / � 1 - z P /8 /6s-s6 / <br /> Signature Date: CCB# (if applicable) <br /> •Applicant is the❑Owner 8rirthorized Representative ❑Authorization to Apply form Attached <br />