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1 <br /> ® CllVE <br /> W, t�.,� Application for Onsite For City Use Only: <br /> DE�at�/ 2020 <br /> __=- ;4 Wastewater Treatment System City ofiii. CC <br /> N <br /> Date Received <br /> MARION (�®�O <br /> MARION COUNTY PUBLIC WORKS Received by �U�i-D�(�G�NSPECT-Io <br /> BUILDING INSPECTION DIVISION Zoning by P_PO S <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/PWBuildinglnspection Activity# <br /> A.Property Owner Information <br /> `10I-1N R MARlcs 283 ErbER pvESE SALEM Dig 973010 503 303-9740 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone II <br /> B.Legal Property Description <br /> DO&v./ 001) ACRE S}LoT6 09 €18AA oa Soo 0..36, <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 2ii4.( D©GWoo1) ACRES 6 <br /> Subdivision Name Lot Block <br /> I (0Z8 DOGwoo) LN SE LyoNs- 0 <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 CA Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ]Authorization Notice for: <br /> El Construction Permit ❑ Permit Reinstatement Kc Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> El Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> 1JONN1 R I''1¢IRK.s so .363-97 4-o <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Z83 E/.DEk AVE 5E, -SALEM ) DR 97306 -34M— <br /> Applicant's <br /> 7306 --34M— <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner El Authorized Representative ❑Authorization to Apply form Attached <br />