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t 0/0-6D01--1 l 1si.a <br /> Application for Onsite <br /> ..11 ,� For City Use Only: Date Stamp:W <br /> --r ;�_� Wastewater Treatment System City of <br /> Date Received ® -EC -EV <br /> :p <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by JUN 5155 Silverton Rd NE Fee JUt® 1 9 2020 <br /> Salem OR 97305 Receipt# MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTION <br /> ON <br /> w <br /> A.Property Owner Information <br /> QgneQr ,� if? score i- Fd &x // f2 i o ., d (L- ?732 5(1Fob /'E36 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal property Description <br /> 0931)33 S-CJ Db i 00 _ _ 07, l,57 11-0-e3 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> L`F I_ )4crcs <br /> Subdivision Name Lot Block <br /> l`f Qq` tatarci Li . 5E- _)_c2-Vfel OR— g 73sS <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 /> 0 Single Family Residence J-Single t:7nily Residence ['Public <br /> Name /- l <br /> Number of Bedrooms Number of Bedrooms 4-Private 2' I CS``ae�K / <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> _ D.Type of Application _ <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> la 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 ❑ 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 /> 'A,'cote Ti'le0eAce-- Sq/- 9&5 9/Se <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 'Pe? &x i t y- 3Q- r5C i 0 tiL ?7 35;2- <br /> Applicant's Mailing Address <br /> r. <br /> ,L(iLe_VU .AA/i --(e-/Le- S ' tq- 70?D <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 1N-Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> 4 ,Cbfe7nc, ell. 'e 1 g E_31P4i (. eoir) <br />