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al -doaL\G\B <br /> , <br /> ., ,,,,,t Application for Onsite For City Use Only: Date Stamp: <br /> �-- Wastewater Treatment System City of <br /> ® I ,[V —1 <br /> Date Received <br /> ims-. , MARION COUNTY PUBLIC WORKS Received by �� `1 <br /> BUILDING INSPECTION DIVISION Zoning by MAR 1 ? 2021 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt4 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> wawww.co.marion.or.us/PWBuildingInsliection Activity# <br /> A.Property Owner Information <br /> 14-1I\ SC�Itdit r ....811 oW4 o d4 Rd J/E 13rodKs, 61? Q13o3 503-792 -33�0 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> 06 2, ( 1 +b B.Legal Prop Description W�/Legal Description [ Tax Lot Acreage or Loto Size <br /> Subdivis,on Name Lot Block <br /> 8?io u (Ova/ id ivy 13 i(ooti C32. F73o,3 <br /> Property Address �� o! City Stat Zip Code <br /> Directions to Property: 4 Q D bln Z Affw <br /> Lo{ <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single'amity Residence 0 Single Family Residence :Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site:valuation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ ons lion Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Rep Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major D Minor ❑ Existing System Evaluation ❑ Personal.Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> I)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 /> j—e95 . e.livii qci 503- 731-290/ 3 323 <br /> Applicant's Name—Please Print Leggy Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 Hash, i;,r LOA 5E t� , 6/' R'7317 <br /> Applicant's ailing Address 1 5q( <br /> 03 °(C ) .5-0// . <br /> Si Date: CCB# (if applicable) <br /> Applicant is the 0 Owner uthorized Representative Authorization to Apply form Attached <br />