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Application for Onsite For City Use Only: RE vEsUfl' in <br /> 4' <br /> .• <br /> _.„,,,,_____;.,,a..„..1.,_: Wastewater Treatment System City of <br /> Date Received MAR 2 2 2021 <br /> MARION COUNTY PUBLIC WORKS Received by MARION COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by BUILDING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> p Salem OR 97305 • I—CPCP 2-- j <br /> • <br /> (503)588-5147 Fax(503)588-7948 Receipt# � ` 3 <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> , _._' _. .,_.' u.__. A Property_Owner Information, _... .�._ . <br /> 5C-0 I-f Ccz.p K, ' O k) SQrttica4 l Gct 1 o c073 (� Et-2..u21- r710-3 <br /> Name Mailing Address J City, State,and Zip (Area Code)Phone# <br /> ._____T E._._ _..__ .. . .__ __.____:_B Legal Property Description <br /> Legal Description Tax Lot Acreage or.Lot Size <br /> Subdivision Name Lot Block <br /> 90 2 , San-ra.wt h w y , g-a--k-5 9 r13,6-1 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> .M x„ N i _ ,,,,33 C Existing,Facility/Proposed Facility/Water Information , ,3 <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence <br /> 3 ,6.c.11ki St 5W) IL'ublic Name <br /> Number of Bedrooms Number o Bedrooms 0 Private <br /> ❑ Other .12-1),..(__D ❑ Other Well,Spring,Shared <br /> .... n..D Type ofApplication . .. . .. .. _._. <br /> ❑ Site Evaluation ❑ Renewal Permitthorization Notice for: <br /> ❑ Construction Permit 1=1Permit Reinstatement eplacing a Dwelling <br /> ID Repair Permit 1:1G Permit Transfer LJ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ 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 /> S C O-r--f C ct.p e K� 731- R/01 - f Z 1023 <br /> Applicant's Name–Pl ase Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 70 (M. Sceri fi c�r1 h wr�1 6a-fc5 ( 0/2_ q r73 yko - <br /> Appl ant's Mailing Address <br /> �� 3/2-7--/2–( <br /> Signature ���� Date: CCB# (if applicable) <br /> Applicant is the❑ Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />