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Date Stamp: <br /> ..404k.,..$ Application for Onsite For City Use Only: (( (� r —1 <br /> City of I <-'1 L 1 <br /> %� Wastewater Treatment <br /> Date Received <br /> r System Received by <br /> R - 2 2007 <br /> Zoning by MAPI.ON COUNTY <br /> Marion County Public Works Fee BJILDINC INSPECTION <br /> Phone: (503)588-5147 Building Inspection Division <br /> Fax: (503)588-7948 555 NE Court St.,Ste.2260 Receipt# <br /> www.co.marion.or.us PO Box 14500 07-0158V <br /> Salem,OR 97309-5036 Activity# <br /> A. Property Owner Information <br /> Dave 'i- Linch /true„din e,- 6,316 A 1 laieues. 1_p• A(. ke-izerOR 5-O3 -7f'.3 -3i.j'6 <br /> Nam �1e• ailing Address City,State,and Zip q3 <br /> � ©3 (Area Code)Phone Number <br /> B. Legal Property Description <br /> 093 in/04 I O i '700 . <br /> t eRai necerintionTax T.ot Acreage or Lot Size <br /> .-Recl 1-1Gf w/c R 1[L1 (Prvpc5e4 3_ <br /> • Subdivision Name ' Lot Block • • <br /> Property Address: 5'54 a lQ ni e / t J r, S, .5 ti. le r' . o'N 9 73 0 !o • <br /> Address City State Zip Code <br /> Directions to Property: S4�u,ili a+k L%h e r7ty Rol, w& 1- n Ca e e)i D r': . <br /> t <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 Igl Private ,---s. <br /> ❑ Other ❑ Other _ Well Spring,Shared <br /> D. Type of Application <br /> ❑ Site Evaluation El Renewal Permit ❑ Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer • 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ ❑AlterationPermit ❑ TemporaryFiousing <br /> Record Review 0 Connecting to•an Existing System Never in Use(over 5-yrs old) <br /> ❑ Major 0 Minor .❑ Other 0 Other—Please Specify <br /> If the requiredfee 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 theabovedescribed property for the sole purpose of this application. <br /> 1�atVrcd A11, nenclin0 er 3D3-74'3-3236 1 io74' <br /> Applicant's Name—Please Print Legibly Applicant's Phone.Number DEQ Lic.# (if applicable) <br /> (03/td ( Yle-/C/ �;P •. (03 Ke lee r CR 9 73 0,3 , <br /> Applicant'sicyMailing Address " <br /> • <br /> D.......„ 1.3, LI 07 (.0,5 7 0.7 <br /> Signature Date • • CCB# (if applicable) <br /> Applicant is the XI Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> S-013/05 Page 1 of 2 <br />