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1 <br /> I ; <br /> s <br /> .w i 0 <br /> 7g — 0 0 3 z6s3 <br /> ,,, <br /> Application for Onsite. For City Use Only: Da ,15 tp: 5 M <br /> Wastewater Treatment System cm'of G® - <br /> ' -- Y z <br /> Date Receivedc) jin <br /> z� <br /> 'i ';�xs MARION COUNTY PUBLIC WORKS Received by 1/0 ® . <br /> BUILD ENG INSPECTION DIVISION Zoning by til C <br /> 5155 Silverton Rd NE 0 f <br /> Salem OR 97305 Fee <br /> (503)588-5147 Fax(503)588-7948 Receipt# z `'�j <br /> ww.co.marion.or.us/PW/Buildinglnspection Activity# <br /> w <br /> A Pro e Owner:Information - <br /> .e_s Pa.v...; k' _ , -tl,„. , \s(71 °P'37_5 ? ,S3)- X69-3 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> - _ B roperty Desncption'-- <br /> -6 4. l f i ) t -b - Legal PAoo <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 1 Subdivision Name Lot. Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> -. ;'C Existing Facility f Proposed Facility f WaterinfOrmation _.. __. . _. .. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence (amgle Family Residence g.ilic SCvfTy ,/s/"I%l/S e 1}l OA* <br /> Name / <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D _T3 ofA�pheation - = <br /> `rii Site Evaluation <br /> ❑ Renewal Permit ❑Authorization Notice for. <br /> • Construction Permit D Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> El Major ❑ Minor ❑ Other El 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 /> 4C-1-\.1) LA) tISO .._ _SC?3 - A*3v7)1_5 3 .07 - <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> k) i--- L' l:-SLa41 c- P-, a`-.� ./vZ-- ‹3 i l c,Jusf--k---__ 0 r-- cr? 3 S-- <br /> Applicant's Mailing Addrlis •. <br /> tiiC tRi 4.9an _5--&- 1, 177 0 L 3 <br /> Sature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative 1,4Authorization to Apply form Attached <br />