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i <br /> Application for Onsite For City Use Only: : Date Stamp: <br /> %: Wastewater Treatment System city of <br /> 111111 Date Received MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DMSION 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/PW/Buildinglnspection Activity# <br /> A.Property Owner Information :. . <br /> `--Rcha.icl -Ti l mo r,c 7070 Li be✓ cl 90-j-emJ 0 I' 63 730(0 \503 -5S i-43700 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> solo_17-04.41: r .iI o q_L:d=f- B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1010 L be--Ii 7c/ --Ski<0, tar'2 q -i 30 <br /> Property Address 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 V Single Family Residence ❑Public <br /> 2. 3 Name <br /> Number of Bedrooms Number of Bedrooms EirPrivate <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D _Type of Apphcahon:_: _.__ <br /> ❑ Site Evaluation ❑ <br /> Renewal Permit ❑ thorization Notice for: <br /> El 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 /> ❑ Major ❑ Minor ❑ Other ❑ 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 /> Richard ;bvtare. 503-557-8 7Oo <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> -7 CID Li der wgcl S actem, Of q 130Go <br /> Applicant's Addq�ss <br /> oe -5-2.q 161 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Wwner ❑Authorized Representative ❑Authorization to Apply form Attached <br />