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! . <br /> . . 9,-Oeb ) Le 1 - <br /> Application for Onsite <br /> For City Use Only: Date Stamp: <br /> We ' <br /> • <br /> • Wastewater Treatment System City of <br /> Date Receivedwok • <br /> ^ �� <br /> • Mi. <br /> 0 <br /> MARION COUNTY PUBLIC WORKS Received by .1. E l� <br /> -BUILDING INSPECTION DIVISION Zoning by teh <br /> 5155 Silverton Rd NE Fee I �lR 05 2019 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> Receipt# ,` � U�.�1®� <br /> www.co.marion.or.usIPWBuildingInspection Activity# 130pL�,iNIG 4SPF <br /> A:Property Owner Information - ' <br /> 13.R.4.10g 64 J / / 1/74 2 L`.aar- • 7 . XS2 a8? 4ei31.0 q°7302— <br /> Name Mailing Address City,State,and Zip 1 '(Area Code)Phone# <br /> • B.Legal Property Description • 6753—s--69.--9.37H°Ti -K3/)3:Q..26 ae 7:z- gee 4/00 - • . ice <br /> Legal Description Tax Lot Acreage or Lot Size• <br /> in ' <br /> -�1,7 Subdivision Name <br /> / Lot Block <br /> qS -5a n ny.�i Cf-e- / n S. ZA LYL o4. q 7 3O(, <br /> Property Address City State Zip Code <br /> Directions to Property: N.wi L!a(2 J 7 c,-,t,n n y sty 04,. //y60, [X-. <br /> C.Existing Facility/Proposed Facility/.water Information ' • <br /> • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> NiSingle Family Residence ®--Single Family Residence ❑Public <br /> n - cr Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private - 1J/ZL . <br /> ❑'Other ❑ Other Well,Spring,Shared . <br /> D.Type of Application' <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction P ermit El Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit - ❑ Permit Transfer U The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> • ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Maj or ❑ Minor ❑ Other _ ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ' ❑ Other—Please Specify. <br /> • <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 /> far° ,Qr_Lo C.( • 6-e 3—sing' —Q'.-?7e' <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number . DEQ Lic.# (if applicable) <br /> /(7e,Z. Zjien ' 2 Q ,g.4-_. As8 aR 1 �� 73 9 2 . <br /> Applicant's Mailing Address • • . . <br /> • <br /> m% • <br /> 0 • <br /> .- 9 . <br /> ignature Date:• CCB# (if applicable) <br /> Applicant is thea6wner ❑Authorized Representative 0 Authorization to Apply form Attached <br />