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5 S-5--- `2-I- 010 (:;7�� Pr ft <br /> , , 44 Application for Onsite For City Use Only: Date Stamp: <br /> y;- v Wastewater Treatment System city of. <br /> ��.."'""�""� y IIIIIII Date Received � � � � � � '�1 <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by OCT 22 2021 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION. COUNTY <br /> www.co.marion.or.us/PWBuildingInspection Activity# BUILDING NSPECTION <br /> ', ,'i,:, w ..... ,� . ....., A, ._ m,u __.. , � ... ._ , � , ., .- .. <br /> Property Owner Informatoin '1 <br /> = 03471eron M1b w cet+fills OR.SE i r'na; © �II/ g7, 92- (5U3)'71- 2766 <br /> Name Mailing Address City,State,and Zi (Area Code)Phone# <br /> B.Legal PropertyDescnption <br /> Legal DesdriptioV4 Tax Lot Acreage or Lot Size <br /> 5LM15et Fl Iis g i-,71es (7 .2/ <br /> Subdivision Name Lot Block <br /> 24 UU sdH Tri Its f7►e.SG Twiquir De. 9 73 61 2- <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C:Existing_Facility/Proposed Facility;/Water Information rt <br /> Existing Facility: Proposed Facility: Water Supply: <br /> O Single Family Residence 0 Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms�- 0 Private We l 1 <br /> O Other ' Other Shop &cflr awt.. Well,Spring,Shared <br /> _.. y ... f D. .. _f Appycapon . ...._. <br /> Type of % <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for:. <br /> ,M. 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 /> PIWPAAW/1) (bibX b nd, LACi (513)&87-gto7o 3ei3.74 <br /> Applicant's Name—PleaPrint Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P.O. Yhot l(QD Sulk wit kr OV2v. t7 gc <br /> Applicant's Mailing Address <br /> WM V 1 -16-9-U2�1 �105 2- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner gi Authorized Representative 0 Authorization to Apply form Attached <br />