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AppCiDate Stamp <br /> Wastewater TreatmentlicationforOnsite System ciFor nrty Use Only: <br /> Date Received <br /> S allMARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww.co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> A.Property Owner Information <br /> Ito Z8'}2t13 C&ti•,) <br /> Ot'llia.., i Carol .5t.,ile.mt 3og Antcenr Wi) Rat5E Seffars.s4 oR TIS52. izo-at't- 2..t14 czar.,(‘) <br /> Name ' Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 4 -31.4 -Ib - Yon 62. Y94 - (z5 S. Si A <br /> Legal Description Tax Lot Acreage or Lot Size <br /> xi 00 <br /> Subdivision Name Lot Block <br /> • . . t _ E Tsifars-od 0Q 91351 <br /> Property Addres /City State Zip Code <br /> Directions to Property: TAICC i--,•:,1- 243 060 .f r-5. Ge 4t4 as q..nvc.nr Wil Rd 6,,, 7 t- ifKat.5. <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ®Single Family Residence IS Single Family Residence ❑Public <br /> 3 Z Name <br /> Number of Bedrooms Number of Bedrooms IN Private W lit <br /> ® Other a a.,,.,. ❑ 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 /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> a Alteration Permit ❑ Record Review ❑ Temporary[lousing <br /> 5 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 /> 3Zo till -2.s93 C8• (k) <br /> tai;(1:0.•... k Ca<oI Siat-Ic.ts no Lin-illy Cco...l'i) <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 33o% Amicwy 14-" Rd . 5E Se;._Ac0N 0 '01351 <br /> Applicant's Mailing Address <br /> W ill f.... A. Scat-us <br /> &t&a .=3.. qt.--; 24 M o•rc-L, 1.0 14 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the g Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />