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020-tb i aS)), <br /> . <br /> Application, for Onsite For City Use Only: Date Stamp: <br /> —.=--.---------,,,7---Z' Wastewater Treatment System City of <br /> Mt] Date Received <br /> Received by <br /> 1 E C-FVfEr) <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION Zoning by <br /> L.9 <br /> 5155 Silverton Rd NE AUG 12 2022 <br /> Fee <br /> Salem OR 97305. <br /> (503)588-5147 Fax(503)588-7948 Receipt It <br /> MA"IION COUNTY <br /> # <br /> wwW.co.marion.or.us/PW/BuildiagInspection Activity BUILDING INSPECTION <br /> A.Property Owner InformatiOn <br /> /76/ 140A s ey Re) S ,weed4 Or' Qr7304 S'az. - .3 il 7Z.- <br /> Name N./failing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Pnverty Description <br /> Legal Description Tax Lot Acreage or LOt Size <br /> WI eA ? e/ <br /> Subdivisitin Name Lot Block <br /> ED 1 S. Eloy'tc.tovvc4.. Oe. 5e: 5c.4( f AA. CD r q 7 3 i 7 <br /> Property Address City State Zip Code <br /> Directions:to Property: <br /> C.Existing Facility/Proposed Facility./Water Information <br /> Existing Facility: Proposed Facility: Water Supply:- <br /> ['Single Family Residence arSingle Family Residence OPublic <br /> 3 Name <br /> Number.of Bedrooms 'Number of Bedrooms 0 Private <br /> 0 Other 0 Other <br /> - Well,Spring;Shared <br /> D.Type of Application <br /> EJ Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> Ef Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> 0 Repair Permit 0 'Permit Transfer O The Addition of One or More Bedrooms <br /> ElEl Major El Minor 0 Existing System Evaluation 0 Personal Hardship <br /> Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major Ej Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El Other—Please Specify <br /> If therequiredfte and attachments are not included with this appliCatiOn, it Will bereturned 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,popnisSion.to enter onto the above described property for the sole purpose of this application. <br /> D kric.,k4) C f er Sti3 qz/9 43f4. <br /> Applicant's Name—PleasePrint-Legibly Applicant's Phone Numbgr DEQ Lic.# (if applicable) <br /> A0 <br /> e"7/..c6 /4c:el?? 6- ,,' Y Q 7 SO 7 <br /> e.... i 1/4 re oie- ;' <br /> Applicant's Mailing Adcliess <br /> Signature. eli Date:( f CC11# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized kepresentative 0 Authorization,to Apply form Attaehed- <br /> . <br />