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IL - bbLVoc'S' I <br /> Application for Onsite For City Use Only: nm.stamp: <br /> City of D ECr�— NE <br /> Wastewater Treatment System Date Received II'''I v �I J11 <br /> MillMARION COUNTY PUBLIC WORKS Received by ,UN 2Q 2016 <br /> BUILDING INSPECTION DIVISION Zoning by ti U <br /> 5155 Silverton Rd NE Fee <br /> Salem OR MARION05 AHION COUNTY <br /> (503) 8- (5 <br /> Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marioaor.us/PW/Buildinglnspection <br /> Activity# <br /> A.Property Owner Information <br /> DO �✓a' tkcrry LI Nc,6 b•^v1 O'n' (9np-/Y -d.69? <br /> Name ` U J /slue ilia". <br /> Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1k0 ei<k z+ H�66 U2 %703,2 <br /> 'b�r`7 , <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 0 Single Family Residence DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms ® Private C..c/CII <br /> O Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ✓ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Majnr ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> Temporary Housing <br /> M <br /> O Major ❑ Minor ❑ Other <br /> ❑ Alteration Permit 0 Record Review ❑ 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 EnvironmentalEnnlQuality permissionioto enter ontonttothe <br /> above described property for the <br /> soleolpurpose of this application. <br /> SPan k41.c-+o/1 ( Coa ] 0 9/ " 7?I D -�Of)o 1 <br /> A optic Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Name—Please Print Legibly pp <br /> A) dog -s-7V CGIim or_ <br /> Applicant's Mailing Address <br /> ----r---- - y -sqc <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0Owner atAuthorized Representative ❑Authorization to Apply form Attached <br /> P <br />