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i <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of ' `� ,— <br /> Date Received <br /> 1111111 MARION COUNTY PUBLIC WORKS Received by Il <br /> BUILDING INSPECTION DIVISION Zoning by OCT 2 4 2018 <br /> 5155 Silverton Rd NE Fee G <br /> Salem OR 97305 Receipt# '�� �'®UnJ� <br /> (503)588-5147 Fax(503)588-7948 BUILDING In1SP <br /> www.co.marion.or.us/PW/BuildingInspection Activity# �CT�®(� <br /> (PQ 9. . W ) g)'a _ A.Property.Owner Information . _ <br /> '/,i '''ft 90 02 R77 P0(44,S-' PI s .'oloiD 1e97PG 9?/m2o5 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 2 'go? (c; s km sF 9 hyo C <br /> Property Address <br /> p �' ' City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 7� n,le .mily ' idence Single Family Residence ❑Public <br /> Nu i.. o.Bedrooms Numbetrof Bedrooms 0 Private <br /> Nfiutai/ <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ` .. <br /> ,❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> i Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer <br /> ❑ The Addition of One or More Bedrooms <br /> 0 Major 0 Minor <br /> 0 Existing System Evaluation 0 Personal Hardship <br /> 0 Alteration Permit ❑ Record Review <br /> ❑ Temporary Housing Major 0 Minor 0 Other <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 1 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 /> Jesus , liocrad' 97 ( 2vo Applicants Name—Please Print Legibly A plicants Phone Number Lic.DEQ # (if applicable) <br /> 90 (larmeey 5 5 sae ibn1oIZ 976 <br /> App' ant's Mailing Add s <br /> 70702 Of / <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ,uthorized Representative 0 Authorization to Apply form Attached <br />