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poopi-1,7 443 -s 7119J 41/4VS 6 <br /> , �� <br /> 404344,,,.....7, <br /> Application for Onsite For City Use Only: Date s p: " 1, <br /> - - :: Wastewater Treatment System <br /> City of, __ ‘.c1--003 3-- EVA <br /> Date Received -_ __ E (C ffi n /7 <br /> ' �w// <br /> MARIONCOUNTY PUBLIC WORKS Received by <br /> E D <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee ._...,r._...__.._ ....,t.. _.r <br /> MAY 24 2019 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(003)588-7948 Receipt#__ - -_s MARION COUNTY <br /> rvt <br /> � .ct sr2fi r, or a sirC /13 11tiin ln5i)L' t On <br /> Activity# N <br /> �UILDI INSPECTION <br /> A.Property Owner Information <br /> ...2,7', '-( -‘72‘1D „�v . L112-- t#t lz`S: .ul -VI ',7 1%`��� 1'-a - t. Cr^i q J, = {' 1:61 4 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone ii <br /> B.Legal Property Description <br /> -s...',__q 1,:3`, 12 c)c) �F ? E s.4 c>0 rs)k2 ti, v—^-.'5 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> .3 <br /> 2 <br /> ____ _ r. t. <br /> Subdivision--- <br /> _ �-\.._.___,_A____ __._. Lot - __. --- Block <br /> Nam <br /> Property Address a City State Zip Code <br /> Directions to Property <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> [Single family Residence tit Single Family Residence OPublic <br /> ,'i <br /> Name <br /> Number of Bedrooms Number of Bedrooms �t <br /> : Private e'';---1(:-.5.f..4-2-., wi.'L''L. <br /> O other �.__. 0 Other _ _ :. .._____w Well,Spring,Shared <br /> D.Type of Application <br /> 0 Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction.Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit. 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> • Major 0 Minor• 0 Existing System Evaluation 0 Personal•Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 theentrance 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 /> ent of Environmental Quality,permis 'on to enter onto the aboye described property for the sole purpose of this application. <br /> l S MP3--77/ 6itt <br /> fl -6 f <br /> Applicant's Name-Please Print Legibly Applicant's Phone:Number: DEQ Lie.# (if applicable) <br /> Applicant's Maili d;, Addres <br /> /- <br /> le ..ii,AA' £2-4 ." S---,02 3 ?csi r <br /> aa,- �•.....,4;e .®� - I ate;6 �a d CCB#(if applicable) <br /> S'- a 3 <br /> Applicant is the P31 Owner $ 1 Ii ZIAuthorized Representative 0 Authorization to Apply form Attached <br />