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U55-2._I-o I 3 bS— er <br /> n,, ., Application for Onsite For City Use On'y: Date Stamp; <br /> ( City of l <br /> am <br /> _ Wastewater Tr atment System . icEllv l�W Date Received 1S <br /> MARION COUN PUBLIC Received by 1 <br /> R <br /> BUILDING INSPECTION DIVISION Zoning by CT 13 2021 <br /> 5155 Silver4on Rd NE Fee Mq <br /> Salem ok 97305 BUILD/ 'OONTV <br /> (503)588-5147 Fax(503)588-7948 Receipt.# G INSPEC <br /> www.co.marion.or.us/PWBuildinglnspection Activity# �IQ� <br /> A.Property Owner luforniation <br /> S tsict1'41 tit-aSti <br /> G + 55154 Ko-r k C4 G6. . .tg..AA. Ott, el-7317 5'01-ei` 9.- `7 a <br /> Name Mailing Address City,State,,and Zip (Area Code)Phone it <br /> I B.Legal Property Descriptior ' <br /> oe t 3 0 c11 s t 3 O A�` t .13 e.efrer. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 5 4 Mark S& .:ice OP. 4-73 ri <br /> Property Address City State Zip Code <br /> Directions to Property:Talc, 1Cv-e eles- lekilk 0 vc TSB 114., ® d. . Sae"Age, SE, T,tr.., <br /> Ks, Tat.,tjte)d ..9bG� toe„.i, -r.itL, fly I"I o.ex. G�I 55-fx Q �,...1e - co...6 <br /> C.Existing Facility"/Proposed Facility%Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence ❑Public <br /> Li Name <br /> Number of Bedrooms Number of Bedrooms a Private VJd t t <br /> ❑ Other ❑ Other I Well,Spring,Shared <br /> D.Type of Application, <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: . <br /> ❑ Construction Permit ❑ Peralit Reinstatement 0 Rel lacing a Dwelling <br /> R.Repair Permit ❑ Permit Transfer ❑ Thd Addition of One or More Bedrooms <br /> O Major X Minor ❑ Exisi ing System Evaluation 0 :Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> O Major ❑ Minor ❑ .Othe ❑ Connecting to an Existing System Never in Use <br /> (oser 5-yrs old) <br /> _ ❑ Other Please Specify <br /> If the required fee and attachments are no included with this application, it will be retu rated to you as incomplete: <br /> Post the orange card at the entrance to the Property. Flag the test holes. I <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 /> 3aii,es Mwrfl akuskt 503 -4749- v3 1 Z 7g08 <br /> Applicant's Name—Please Print Legjlzly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> 3a9 46 G ,..36' Lc.i0 .. 0V-1735) <br /> 5S2Li Nvxr k c- C. Sate.. ., o it 41-1 3 17 <br /> Applicant' Mailing Address <br /> Si e " Date CCB# (if applicable) <br /> 46 <br /> Applicant is the Owner 0 Authorized Representative i Authorization to Apply form Attached <br />