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i <br /> al-bc a11 RECEINEn <br /> io <br /> Application for Onsite <br /> APR 2 2 221 - <br /> w4v"� For City Use Only: ate Stamp: <br /> 11 <br /> --- � Wastewater Treatment System city°F MARION � �_� <br /> Date Received le Et <br /> MARION COUNTYReceived byC <br /> PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION Zoning by I 1 <br /> 5155 Silverton Rd NE <br /> APR 0 9 2021 <br /> Salem OR 97305 Fee <br /> (503)588-5147 Fax(503)588-7948 Receipt MARION COUNTY <br /> www.co:marion.or.us/PWBuiidingInsnection Activity# CEJ{LDING INSPECTION <br /> kn A Pro <br /> ..�._ ._;,,.��.�.��..a,� .�_ -_. ,a...��. �.:�.A3_�.. ..:_ . P�i�YG!�tnicr,�Informa�n.a _.. � �.� <br /> Susan Smith 22955 Scott Ln NE Aurora, OR (503)593-1479 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ''' ,.2:. 1Ni- N. , wa`x „0,.Legal PropertyDescriptio t s r <br /> 041 WC613 �._vim <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 22955 Scott Ln NE Aurora, OR OR 97002 <br /> Property Address City State Zip Code <br /> Directions to Property:. <br /> r.. s. ', . .,.,. ,i.,.,._.-._ xistin ` oposed acility/ WX1tLr Info jnatt rk' h*; n <br /> Existing Facility: Proposed.Facility: Water Supply: <br /> ®Single Family Residence 0 Single Family Residence ❑Public <br /> 3 <br /> Name <br /> Number of Bedrooms Number of Bedrooms <br /> ❑ Other ❑ Private <br /> 0 Other Well,Spring,Shared <br /> _ a <br /> - g > _ ;.t . s D''TXPeofwApplication z T <br /> ❑ Site Evaluation ❑ Renewal. Permit „o <br /> ❑ Construction Permit ❑Authorization Notice for: <br /> ❑ Permit Reinstatement <br /> ® Repair Permit ❑ ,Permit Transfer 0 Replacing a:.Dwelling <br /> ❑ The Addition of One or More Bedrooms <br /> Major 0 Minor <br /> ❑ Existing System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit ❑ Record Review <br /> ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> *Replacing 100'of line ONLY (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 giant 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 /> Lip Stinky Environmental Service, Inc. (503)351-8715 38231 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 19631 Kolar Dr, Oregon City, OR 97045 <br /> Applicant's Mailing Address <br /> 3/29/21 189693 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the.❑Owner 0 Authorized Representative ®Authorization to Apply form Attached <br /> i <br />