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Application for Onsite Far c;of use Only: G 3:;" <br /> r.Stama fin <br /> z- <br /> Wastewater Treatment System City x <br /> Date Received zG, n <br /> MIN <br /> Inli <br /> MARION COUNTY PUBLIC WORKS Received by Z n _.1BUILDING INSPECTION DIVISION Zoning by co O No .� <br /> 5155 Silverton Rd NE Fee Ill C �� <br /> Salem OR 97305 Receipt# 0Z m "�(�" " <br /> (503)588-5147 Fax(503)588-7948 <br /> ww.co.mari .or.us/PWBuildinglnspection Activity# <br /> won 0 lC7l <br /> Z <br /> A.Property Owner Information _. <br /> \Ji llamelke. Un;Vf 4tc 900 a-l-e Se SIl o-, 02 9Z?()I 503 370-(!X)3 <br /> Name Mn 6ui ' g Address City, State,and ip (Area Code)Phone# <br /> V B Legal Property Description _. . <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> a8855 Hoi+k f vK.P_sI• I -eka r-in OZ, 97309 <br /> Property Address /^, City State Zip Code <br /> Directions to Property: !* YOX S 0-p l4` ll , will, / ds <br /> t �o k- ve5+ me Carson at �'• aur <br /> (MP{he i+rK+ s,(IQ.. 1-r7L{,' lake, rrm&ac,Y Go (a✓ mr4 WiIkrnr{kt' V. <br /> C Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> yl Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> O Other 0 Other Well,Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> E Construction Permit E Permit Reinstatement ❑ Replacing a Dwelling <br /> RI Repaira� Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Xsl 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 /> 5 Other—Please Specify <br /> If the requiredfee 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 /> On-Sire G IC; EXCauct-1 -n / <br /> Jet Ce n a leZ • 503 3c2--7000 3(-�-7r41n <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> T U 5a4 ( ci7ol-err,. C) 973024 <br /> Applicant' ' ailing Ad. ess <br /> 4 tA ,- AkikA . il Mnv-cn z , 20i8 3G-78C <br /> g "e — / Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative Authorization to Apply form Attached <br />