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-1- " <br /> Ck—nCi'D t .C1\ <br /> Application for Onsite For City Usc Only: Date Stamp: <br /> ...... <br /> Wastewater Treatment System City of ID)Mg -r-4 CIE V7--7-c; 111) <br /> 1 E,MARION COUNTY PUBLIC WORKS <br /> DateReceived <br /> Received by <br /> BUILDING INSPECTION DIVISION Zoningby ' JAN 23 201P <br /> 5155 Silverton Rd NE Fee MI RION COU _ Y <br /> Salem OR.97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt it JUILIANGINSPa, ; ON <br /> www.co.marion.or.uS/P'W/Buildinensuection Activity4 <br /> 10114714:6:24111:ril.1::3211V <br /> Le-e-- PA=e CI e'14 ef 5413- 61whiKoo to.A714k - da 973 ) 77/ -A31-, ).1( <br /> Name Mailing Address• • City,State,and Zip: (Area Code)Phone 4 <br /> B.Legal Property Description <br /> Legal.Description Tax Lot Acreage or Lot Size <br /> rtfte.e.51- Ltk,A4 ,S' kk eS 9, <br /> Subdivision Name Lot Block <br /> III 6. \) e ' .., ' q , O--11-ix-y-\ /"...i.. ...„..e....., <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> Qr;41011:71117,410giiiinifOr4Ir Zi WW1.7 ft,.",":"7,7•°4' <br /> Ex4ting Facility: Proposed Facility: Water Supply: <br /> OSingle Family Residence 0 Single Family Residence 0Public <br /> G Name <br /> Numberof Bedrooms Number of Bedrooms 0 Private <br /> O Other 0 Other •Well,Spring,Shared <br /> D.Type of Application <br /> O Site Evaluation 0 Renewal Permit ['Authorization Notice for <br /> CI Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Yie Repair Permit 0 Penult Trartsfer 0 The Addition of One or More Bedrooms <br /> 'Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> O Alteration Permit 0 Record Review '0 Temporary Housing <br /> D Major 0 Minor 1:1 Other. D Connecting to an Existing System Never in Use <br /> • (over 5-yrs old) <br /> 0 Other-Please Spedify <br /> 1f 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 entranceio 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 ofEnvironmental Quality,permission nt,enter onto the above described property for the sole purpose of this application. <br /> I-1'5e 44 I e 'i 4•".4.-k-r 44.4.'t e-X'We• 59 l''' 41 ii C.)'Nil%7 et 3710S <br /> Applicant's Name--Please Print Legibly Applicant's Phone Number DEQ Lie.'4 (if applicable) <br /> '.2 4p 4(S.- (bc-c,....,s-k-...- e .. 1-e- c.i....c.,‘ 0 e 17 3 <br /> Applicant's Mailing Mailing Address <br /> / - 7- 1 ? it i30 <br /> Signatu 4.,< Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized.Representative %Authorization to Apply form Attached" <br />