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020-ndl ' 33 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> .--77-7-7 ,----21" Wastewater Treatment System City of <br /> IIIII Date Received <br /> Received b '� <br /> MARION COUNTY PUBLIC WORKS y � � <br /> BUILDING INSPECTION DIVISION Zoning by OCT 0 7 2020 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION C, UNT Y <br /> (503)588-5147 Fax(503);588-7948 Receipt# <br /> Activity# BUILDING ii <br /> www.co.marion.or.us/PWBuildinaInsnection <br /> t'ECTION <br /> A.Property Owner Information <br /> Kr-c. L 1D-eL qn 8393 eed54ec t1 S'ilCM J OR 97306 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> OR 3k/ 33A B.Legal Property DOcription , / <br /> a <br /> Legal Description Tax Lot Acreage or Lot Size. <br /> Subdivision Name Lot Block <br /> 83 J3 7�e frfrrc . ✓r. .Sc Sgkw) 6e <br /> Property Address City State Zip Co e <br /> 7,T <br /> Directions to Property: 0 ' Lv+4J?4I �1 It <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Exiptg Facility: Proposed Facility: Water Supply: <br /> Single Farpily Residence El Single Family Residence ❑Public <br /> �![ Name <br /> Number of Bedrooms umber of edrooms Er/Private ei <br /> ❑ Other Other /i pjDi pring,Shared <br /> D.T e of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ? [ to on Permit ❑ Record Review ❑ Temporary Housing <br /> • [v 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,authorizedagent of the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 3-055 Kt. eilor' q 5-03- 73Z-2ya/ 3‘32-3 <br /> Applicant's Name—Please Print Legii y Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3890 ISA Gini;r L►OA� S 4.fl•l, O <br /> S / 97317 <br /> Applicant's ailing Address J� <br /> 11.1Pw. 1 fiVoi/2., ,c0/7/ <br /> Date: CCB# (if applicable) <br /> Applicant is the 0 Owner EeLhorized Representative [orization to Apply form Attached <br />