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sjy_ 21 o O 7? 2-- Prr <br /> Application for Onsite For City Use Only: Date Stamp: <br /> iii--� :� Wastewater Treatment System City of --� <br /> 'P Date Received, D L� [ '� <br /> MARION COUNTY PUBLIC WORKS - Received by <br /> BUILDING INSPECTION DIVISION Zoning by JUL r 0 2021 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# IUTARIO V COUNTY <br /> ww.co.marion.or.us/PWBuildingInspection Activity# BUILDING INSPECTION <br /> w <br /> A Property Owner Information <br /> � > ✓r23-Vs_7 59741 <br /> 2/f4 t ec'Rp 2e�D9 ,v 8,VAZF6 ? 'TT'4 OR 972/z <br /> Name .. Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Leal Property Description <br /> Oa YES/ oavoo 2,1-9, g - —= <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block <br /> 31497 popryroAx f',9 - G.,>/o v.� G✓,9 173s'g <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 Igi Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms lal Private 4/E4L. <br /> ❑ Other BC/R/t/ED • ❑ 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 /> O'.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 /> ❑ 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 /> aeis G,e t, zoo-977-/S®.3 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /23®3 P7 ,9iR- 14/61' ,/e .' 77e' I„/4 l''/2X <br /> Applicant's Mailing Address <br /> eit--ZOX7' <br /> 730 -- z l <br /> Signature Date: CCB# (if applicable) ' <br /> Applicant is the❑ Owner NrAuthorized Representative ❑Authorization to Apply form Attached <br /> GAFORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />