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Application for Onsite For City Use Only: <br /> — ;��� Wastewater Treatment System City of IEC E <br /> M_ml <br /> Date Received <br /> , <br /> BUILDING INSPECTION DIVISION Zoning by <br /> Ili MARION COUNTY PUBLIC WORKS Received by MAR 2 9 2019 <br /> 7 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 - �� <br /> wnw.co.marion.or.us/PW/BuildingInspection Activity# �., c '�3( <br /> A.Property Owner Information <br /> "o i-( ercDI.Pl` 9f139 v;ow" oit4,t-t2dNC Si\ve.✓$ov‘io22 ¶381 503.5041. 2433 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 0'71 bUO2b ¢ tQ o4S SR Acv <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 418'9 v;c-b,r Poi ta 11/416- %;tveArk.o►ti o t2 C1-11$1 <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 0 Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms 02 Private We-1t <br /> O Other is Other 'Boar v_ Well,Spring,Shared <br /> D.Type of Application <br /> igl Site Evaluation 0 Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> O Major 0 Minor 0 Other 0 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 /> Sct,.v,. i' edcrl;vS03 • So(1 • Zo33 <br /> Applicant's Name-Please Prin Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> LIl$9j Vi'ctbr -Poi,A.A. ad NE/ S;tveri-ohl OR.. g13at <br /> Applicant's Mailing Address <br /> %Ai. C I Ci . MEAN' ii) 20 <br /> ISir ature Date: CCB# (if applicable) <br /> Applicant is the TA Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />