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• <br /> • <br /> I9- 0o 22.69 --?gm7- <br /> . <br /> Application for Onsite Tor C.tiy Use only: <br /> - _; Wastewater Treathient System <br /> City°f - <br /> ----= --,s . Date Received • q 1�' r [� V <br /> ' MARION COUNTY PUBLIC WORICS Received by 1. L ) <br /> • BTX_LD tG DISPECT.ION DIVISION. Zoning by MAR 26 20. 19 �y <br /> 515 Silverton Rid ltE 16 <br /> Fee <br /> .. Salem OR97305 MARION COUNTY <br /> (503)588-514-7 Fax(503)5S8-7940 Receiptr - BUILDING INSpECTIO"' <br /> www co.marion,or.usPP rW/BufdiF:inspection Activity r <br /> - __ ._ - - --. - _ - - _ _ _-A.-Property Owner Infoiafion-, . .. _ : _�: •=_ : - - <br /> 6-/ 3 v C>it 5_5 ,vel, st . -w w i l(e Or g 1,S?�5 <br /> ?Nameivfaitin'Address City,State,and;Zip (Area Code)Phone <br /> - <br /> - ....:::'.f -_-:--:_.--:•f:-..-:-.-_.:.- -c:-'-:-...- - - --=-- _B:-Z. g4 Prouerty-Deseiipf on. - _ - . • : - - : - <br /> Legal Description Tax Lot Acrea_Ee or Lot Size <br /> Subdivision Name Lot Block <br /> • <br /> I' .-.1 ....;5 e j �4 1,fLfe._ l_1•__ 9 73 2.5 <br /> Property Address City State yip Code <br /> Directions to Property; <br /> :::-----7. :F. stmi-tacilh.P opo`sed. 04.60 a+er:Iazoi ig--ii=-'=-_'. -- ----2-- - .. <br /> Ezis 4.s Facility: Proposed Facility: Water Supply: <br />' I Single Family Residence ❑ Single Family Residence ❑Public -. <br /> 3 Name - <br /> Number ofBedrooms Number ofBedrooms ❑ Private w'e,11 <br /> Other_ - <br /> _•' .•---_-_ _- - --- -- - - _ � Other - - - _ - _ _ _ �e�S Shared <br /> -"==:• -._ - - ..:---_:.-- --1'::...:-,-:._. D:Tvpeofapplcatton--- - ---= �t - <br /> [T Site Evaluation�-.---• --1 � -Q Renewal Permit - - -._ -.., _ . --- - <br /> ❑ Constru ration Peraj 0 Permit Reinstatement ❑Au Replacing Noticewell ng <br /> ❑ a Dwelling <br /> igi Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 ivimor 0 Existing.System Evaluation ❑ Personal Hardship <br /> ❑ .AIteratisn Permit ❑ Record Review 0 Temporary Ho' irm <br /> ❑ Major 0Minor 0 Other 0 Connecttnz to an E-xisting 5 Never inUse <br /> ysrem_" <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> Tf the ree:pired fee and attachments are not included with this application,it will be retia-nedto you as incomplete. <br /> Post the orange card atthe menace to the property. Flag the test holes. - <br /> By my sia++ ..I certify that the information I have fiunisheci is correct;and hereby brant Marion County,authorized agent of the <br /> Department ofEnviranmenral Quality permission to enter onto the above described property for Ate sole purpose of this application. <br /> Her hoyri- e IAILISon JR. 503- 673-7/57 37 003 <br /> A.pplicant's Name—Please Print Legibly Applivaut.=s Phone Number. DEQ Lic.- (if applicable) • <br /> 277B C s d 'ILvu_ E S;IUe,- tb '73 de 1 <br /> A.pplicant's Mailing Address-, <br /> 1,41/1 c tA) v* ,. 9,2, <br /> ii`!ature Date: CCB fF Crapplicable) <br /> ) <br /> %ppiieantis the 0 Owner ❑Authorized Representative 17.4 Authorization to Apply form=ached <br />