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• <br /> Application for Onsite Far City Use Only: o <br /> ellWastewater Treatment System Cityof � � \v/+tl��.: <br /> Date Received _ _. <br /> Illiii MARION COUNTY PUBLIC WORKS Received NOV ,�I�� G <br /> BUILDING INSPECTION DIVISION Zoning by MARION( jly�-./ <br /> 5155 Silverton Rd NE Fes (-©It1f IN6F>=p1?Oh1 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt k <br /> Activity ti <br /> // ///fh4 // wuw.co.marion.or.us/PW/Buildinglnspeclion <br /> L//a„4A S e/A—,„,rc” US AP/a+/ A.Property Owner Information <br /> /Of 7s el- E�y,...i.s 3Y939 /L 5- <br /> 44fi00+ /ly en A- Qt 973% 563-897-5733 <br /> Name Mailing Address City,State,t(nd Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 93 ' `/e .29 71600 66t5 S, 66 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 3yV41 e / 1 ( / / 9/3 ylp <br /> �/U //O.// J6n//am /�jy (Tc.J'lS <br /> Property Address q City State Zip Code/ /� <br /> Directions to Property: t,c k ora^ Se;4.1a.n-�(h-, ./4 Z a - (roc-)j c I' PM. , cell A RIC <br /> 01 /1(�y Gnome - ?/N/ G at., f /ITMi/ U U <br /> i//J C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedro ms _ ® Private <br /> ❑ Other - ® Other fid hhe/in, fag. /.// 0 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 /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ 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 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 /> RAFFGrbA-6/r Si-P/7eSitio/ee SKT:3-(8z- F?7 379/R <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> �eC', lc: Gx // -SC /tJ,Aonce//s, 0 7077/ <br /> Applicant's Mailing Address <br /> PPF //- / - / Z /58-2 ez/ , <br /> Signature Date: CCB ft (if applicable) <br /> Applicant is the 0 Owner Authorized Representativeuthorization to Apply form Attached <br />