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d I r:b b I (f2e <br /> .,.,4-, ..„,„, Application for Onsite For City Use Only: nate stamp: <br /> ---= ;_� Wastewater Treatment System City of i [ C E IJ Vi <br /> urn. _, ., Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by MAR 2 5 2021 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 Receipt if BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildinglnsuection Activity# <br /> A.Property Owner Information <br /> Anf5q Toff 97v arcirciakW4s s4kw, oR 97302 5°3 -Sol- (70 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ' S L I^. rae pi � �. B2. <br /> .Legal Prop� DescriptionO6 ?g <br /> Legal Des 'on <br /> Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> L/7i? eiYG'daft Ref 5- 54/.ice c)/ 7730i- <br /> Property Address Ci / StateZip Code <br /> Directions to Property: lit lit i k • d. >b1 t d (Ai Cj h e W c - � 4( of (�m.) <br /> ¢h <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existlug Facility: Proposed Facility: Water Supply: <br /> llit Single Family Residence 0 Single Family Residence ❑Public <br /> 3Name <br /> Number of Bedrooms Number of Bedrooms �rivate <br /> ❑ Other ❑ Other 0 Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> Repal ermit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review, ❑ Temporary Housing <br /> ❑ Major 0 Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> lithe 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 /> e55 F,. e. ,,,24/1 qu 503--93z 2 */ 3j32.3 <br /> Applicant's Name—Please Print Legj y Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 kci iknl;w LJA 5E 5 clfwli bg (/7317 <br /> Applicant's ailing Address <br /> _/� <br /> 3/2y/21 .5"0/7/ . <br /> S -' r Date: CCB# (if applicable) <br /> Applicant is the 0 OwnerAuthorized Representative Authorization to Apply form Attached <br />