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EXPIRED <br /> p,-,-,--,A. <br /> ,)A - 07-15`4 p -mil <br /> Application for Onsite For CityUse Only: <br /> D EA <br /> Y�—�= ; Wastewater Treatment Systemcity of <br /> Date Received <br /> MN MARION COUNTY PUBLIC WORKS Received byJU 3 0 2021BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE BUI�LIN N COUNTY <br /> Fee INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildineIospection Activity# <br /> A.Property Owner Information <br /> I4at erN t.111s PO Box tt'Cl Lyor',5 6/1N g1og �' 5c),- 7 3i�, -1 <br /> 9 - <br /> Name Mailing Address Ci ,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description I` S 1 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 2Sta g 1 o r-k1n 1=-o rl I,. Rc) Ly e n S Ok � � 'C 'Property Address City State Zp <br /> ip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> OSingle Family R idence Single Family Residence ❑Public <br /> / <br /> t JtAC. ,I Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private we// <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Applicati ft <br /> ❑ Site Evaluation ❑ Renewal Permit ►v,Aut, i rization Notice for: r'4- <br /> Construction Permit El Permit Reinstatement . Replacing a Dwelling d'c . <br /> C_) <br /> ' Re air Permi ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> Major Minor ElExisting System Evaluation ❑ Personal Hardship <br /> ElA teration Permit El Record Review ❑ Temporary Housing `, <br /> El Major El Minor ❑ Other El Connecting to an Existing System Never in Use d3, <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 /> CA ,oat-. (1aA-e , l lC n3 - (13 - A 5 qjq () <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1 S J3 .L )e e 11.X:t)c1 Pt (NoC> 1 JA(t(Ai r,, GK (T- 1 3 C <br /> Applicant's Mailing Ad 's o 7 <br /> 1.44,7 1\14,- lia,31 _1 ,2,2cal-d <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ,Authorized Representative El Authorization to Apply form Attached <br />