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Application for Onsite For City Use Only: Date Stamp: <br /> =1� Wastewater Treatment System City of <br /> MI <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> /_ l i r CYoA.Property Owner IInformation z <br /> C vvAr L . ?O i5o �+ l st.gJ (/ R 9707 593^3 '3- 7373 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Z15 193 057 LO o1100 31c. frD <br /> Legal Description Tax Lot Acreage or Lot Size <br /> OFFiC t 1-i-A-S s aA-26-TE A-D1Y2t3S <br /> Snbdivision_Nan Ql/.) jn23 s j EE/'.J Lot Block <br /> $ <br /> —5153 h .P_nU K.d' 6e-ft/ars 0IL 970 Zif <br /> Property Address City StateZip Code <br /> Directions to Property: •75 pi F.,4 by 2 r iz.,( 4- Kit. Li j i i-n c Ito_ <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms [t Private LJe 11 <br /> la Other u tce_15,,,) 10/1., 0 Other Well,Spring,Shared <br /> '3 0 )5 D.Type of Application <br /> 2 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 /> O Major ❑ Minor ❑ Other 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 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 /> (c)Itw,pn Lei C. 503-313- 73 73 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ?. o. &DK �I 51t ,..1 a1Z 97 /3 7 <br /> Applicant's Mailing Address <br /> 77/i s'/i ? <br /> ignature DateCCB# if applicable) <br /> ( PP ) <br /> Applicant is the 0 Owner CK Authorized Representative ❑Authorization to Apply form Attached <br />