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. C21— OrVatS . <br /> ,;,, N, Application for Onsite For City Use Only Date Stamp: <br /> uc <br /> Wastewater Treatment System city of ,; ) <br /> A �,�� L�l���"� 4 ' t <br /> �i�� v <br /> ,34 <br /> MIN MARION <br /> Received <br /> MARION COUNTY PUBLIC WORKS Received by e <br /> BUILDING INSPECTION DIVISION Zoning by DE' 07 2021 ' <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee dAi , COUNTY <br /> • (503)588-5147 Fax(503)588-7948 Receipt# BUILDlisIG INSPECTION <br /> w .co.marion.or.us/PWBuildineInsnection Activity# <br /> ww <br /> A.Property Owner Information_ • <br /> bjef\oht SliA <br /> Name i Mailing Address City, State,and Zip_ (Area Code)Phone# <br /> B.Legal Property Description <br /> nik11q e rn) 1\( t. CSC Itth <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 43k-i \\& rrN 0 XeRefaV\ Oq--- 0►-1 <br /> Property Address n City— State Zip Code <br /> Directions to Property: -`— :., . <br /> • <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 12 Single Family Residence ❑ Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms J Private We// <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> _ D.Type of Application <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> E] 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 /> „ t i ❑ Other—Please Specify <br /> `,�A <br /> If the reg Tired fee and attdchm`ents are not included ia'ith 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P 0 1 o )/ Soy TGt_rner of? 97_312_ <br /> A p ica ' Mailing Address <br /> R 1,Q -- -Q.1 L/ /55I <br /> Sigfiature 1 Date: CCB# (if applicable) <br /> 1 <br /> Applicant is the 0 Owner 'f Authorized Representative 0 Authorization to Apply form Attached <br />