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• 5SS-21-00 -1 \ o1- f. _ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> City of <br /> --- v Wastewater Treatment System <br /> IIIIII,�r„y,;,. Date Received � �/] <br /> MARION COUNTY PUBLIC WORKS Received by DE c <br /> E v <br /> BUILDING INSPECTION DIVISION Zoning by ��� <br /> 5155 Silverton Rd NE 1 <br /> F U <br /> Salem OR 97305 Receipt# <br /> (503)588-5147 Fax(503)588-7948 Activity# MAR ON COUNTY <br /> www.eo.marion.onus/PW/Buildininspection _ RI Ill nING INSPECTION <br /> A.Property Owner Information <br /> re, o e. 0/7Gd2- <br /> Name <br /> Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name <br /> Lot Block <br /> r`o27 qq.c NA, Alui v ar te-,:k_ D l— ( 100? <br /> Property Address <br /> City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: <br /> Proposed Facility: Water Supply: <br /> Single Family Residence ❑Public <br /> OSingle Family Residence SIL Name <br /> Number of Bedrooms Number of Bedrooms )4 Private 4616 .406 <br /> ❑ Other 0 Other <br /> gifii prim" "` <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit cgAuthorization Notice for: <br /> ❑ RepairPermit Reinstatementeig Replacing a Dwelling <br /> Construction Permit 0 [�� The Addition of One or More Bedrooms <br /> fit Permit ❑ Permit Transfer <br /> Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship❑ Temporary Housing <br /> ❑ Alteration Permit 0 Record Review <br /> 0 Major 0 Minor 0 Other 0 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 /> �03 3' .7-//6 <br /> htriG lknIer- , Lic.# (if applicable) <br /> Applicant's Name—Please Print Legibly Applicants Phone Number DEQ <br /> 0 , 001 5 7-/ - Ck 0 R 'q7 0 Z— <br /> Applici Mailing Address �j <br /> � . o[ L- ` -- 0 CCB# (if applicable) <br /> iT'store Date: <br /> Applicant is the 0 Owner <br /> Authorized Representative Authorization to Apply form Attached <br />