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ig- 6 ae-ri J - ?tz c 1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of <br /> NM <br /> Date Received D IEC! j V <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee `� ' � 2 2U l 'rc <br /> Salem OR 97305 MAR 14 N COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <br /> R rte ,► .• ani a. —leeL S-,7 ►- 1 0,Y2—__a -/Sr <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> -(3zS9-61( t c3 ome-0/40 a,, C3 81 a 113(TACO S:vo <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> t3°CCe, avesdi 12eL /u,p-k -L 20 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ®Single Family Residence 0 Single Family Residence ❑Public <br /> Name,, ,/ <br /> Number of Bedrooms Number of Bedrooms 1_' Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> of Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ AlMajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> teration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 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 Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 6e_A„,(4.- v--0).,_ , 503--e - f'4/La .3 ( <br /> Applic 's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> is la z_ -5;74,et e rz3gl <br /> Applicant's Mailing Address <br /> 1 / 6-z2-(8- itC0g-3 <br /> S"_ a;,,' Date: CCB# (if applicable) <br /> Applicant is the 0 Owner OIAuthorized Representative I2.lAuthorization to Apply form Attached <br />