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,T�s=-2 I-0 0 6'2,62- PRNiT <br />IF <br /> •,,, k...._ Application for Onsite For City Use Only: Date Stamp: �� <br /> =%%=� Wastewater Treatment System City of D rE CC. [� 0 <br /> .' Date Received <br /> MN <br /> MARION COUNTY PUBLIC WORKS Received by J <br /> BUILDING INSPECTION DIVISION Zoning by - JUN 16 2021' <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# 11 <br /> A.Property Owner Information s7.. 7 1.'_. -:Z! O 1 <br /> Sraw•k4/40-- @r-amN BSS sq! &kyr ski bbrt'ic4c)J0R �lq2(� c�'? ,i� ° %r�,-5 7�;; s6 <br /> Name - Mailing Address City, State,and Zip (Area Code)Phone# <br /> �'l 00 Q �1( �� B.Legal Property Description <br /> M Cr l;q7,� O. <br /> LI <br /> Legal Desc`iption _ Tax Lot Acreage or Lot Size <br /> Creeir. 011101A. C Z..- <br /> Subdivision Name Lot Block <br /> I`iS k OA SI' f 0-6r014- qq- ciZ <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> E 's ing Facility: Pro osed Facility: Water Supply: <br /> � L <br /> s 3mgle Family Residence, L�Single Family Residence Public CI U� ��7 <br /> ..,2--3 Naame <br /> Number of Bedrooms Number of Bedrooms • ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Au orization Notice for: <br /> UConstruction Permit El Permit Reinstatement ((Replacing a Dwelling <br /> Repair Permit ,J ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ID Major rr 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 /> Somav4111-' MUc Iv.- 1O-:F - Z10 1 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> gs Ts so th r l i,,j. Por-frictild, o. g nt 1 <br /> Applicant's Mailing Address <br /> ._ _ 5 /z-%z-oZ'/ <br /> Signature - Date: CCB# (if applicable) <br /> Applicant is the[s 1Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />