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n w` Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DMSION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildin2Insaection Activity# <br /> A.Property Owner Information <br /> Russel Wilson PO Box 99 Lyons, OR 97358 (503) 859-2134 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 09 2E 18DB 100 14.25 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 22636 Jennie Rd Lyons OR 97358 <br /> Property Address City State Zip Code <br /> Directions to Property: Highway 22 turn right on Jennie Rd <br /> C.Existing Facility/Proposed Facility/Water Information <br /> • tiny Faril' Proposed Facility: Water Supply: <br /> • e y Residence ® Single Family Residence ❑Public <br /> 3 Name <br /> mb Bedrooms Number of Bedrooms ® Private Well <br /> Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit EAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ® Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> Jesus Andrade 3-A Construction, LLC. 971-218-3568 RI 823 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1690 Harvey ST SE, Jefferson OR 97352 <br /> Applicant's Mailing Address <br /> /� 01/21/2021 167959 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑Owner ❑ Authorized Representative ®Authorization to Apply form Attached <br />