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; � Application for Onsite For City Use Only: Dace Stamp: <br /> ` :-iWastewater Treatment System z <br /> Date Received D g 2 2 <br /> LI <br /> V E D <br /> 11.1MMARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by LIAR 21 <br /> 2019 <br /> 5155 Silverton Rd NE Fee <br /> � � COUNTYON <br /> Salem OR 97305 Receipt# �5�� ��( y�r� 1-��� <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> A.Property Owner Information <br /> 7144.._ 362S- ke.A. .. 5E_ _S�(¢�,t "i-ria <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> ,Pest S P 4 ,"--1 PL-0L- 2W-CZ( <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <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 /> 0 Single Family Residence lig Single Family Residence ❑Public <br /> Li Name <br /> Number of Bedrooms Number of Bedrooms p Private A f 6a <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> tf Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor ❑ Existing System Evaluation 0 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 /> (3,4"___ ..- d- ,-L cry 5o�-8 2z-l'—�4-(lt-/ : i c s- <br /> Appli&Ldnt's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PC-l-& 'Z-_ St''Ic ✓T (0/12, c'i`I3SO <br /> Applicant's Mailing •ddress <br /> 3-za-l4t X1682 <br /> Si e Date: CCB# (if applicable) <br /> Applicant is the El Owner p Authorized Representative zIKAAuthorization to Apply form Attached <br />