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kinimm...) MAKIlfri CAJUN'I rurnAt.. IV 1J11111.3 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NEU <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt 4 a <br /> # <br /> t 1 J Ati 2 4 2022 <br /> www.eo.marion.or.us/PW/BuildingInspection Activity dOlYthille <br /> A.Property Owner Information mpooN COUKTY <br /> DinINspEcTioN <br /> 5 zt, 6:,2- ili _, 094‹,c- ----,,,"tin, es< BuIL <br /> /-siiiy,40--, A--.. ----- — ----1`" <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> Ct471-C-(6,1ke <4 B.Legal Property Description <br /> 0 2VAC 0 C-00 il 0 - <br /> Legal.Description Tax Lot Acreage or Lot Size <br /> AVA <br /> Subdivision Name Lot Block. <br /> 51'1&O -/4hrs41-1 Sc- <br /> ,--- .1 kirk (f,34.. <br /> Property Address City , State 775/7 <br /> Zip Code <br /> „--- <br /> Directions to Property: 7ryr r Rd -716 ,L1--kr 4:'ns /2ed <br /> C.Existing Facility/Proposed Facility 1 Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> gSingle Family Residence El Single Family Residence OPublic <br /> Ofil, Name <br /> Numberof Bedrooms Number of Bedrooms El Private <br /> O Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> O Site Evaluation 0 Renewal Permit ElAuthorization Notice for: <br /> O Construction Permit 0 Permit Reinstatement D Replacing a Dwelling <br /> O Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ED Major 0 Minor 0 Existing System Evaluation ..d. Personal Hardship <br /> O 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 S-yrs old) <br /> 0 Other-Please Specify <br /> r <br /> If the requiredfee 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 /> filfa7a1io,f nef.,iik.- ,12/3-8;ei-0 sie6 <br /> Applicants Name-Please Print Legibly Applicant's Phone Number DEQ Lic.it (if applicable) <br /> --576-(2 (5r4 <br /> "-.. LA ir.L. 55: <br /> Ay licant's Mailing Address <br /> : <br /> II; <br /> IS onaithee - <br /> b Date: CCB 4 (if applicable) <br /> Applicant is the 0 Owner 0/Authorized Representative 0 Authorization to Apply form Attached <br />