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c)/1-,t) , B5,LQ°‘ <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city°f <br /> -~ .- ME_ -0'\ <br /> ..,.� .fi Date Received E C L <br /> MARION COUNTY PUBLIC WORKS Received by _�J <br /> BUILDING INSPECTION DIVISION Zoning by AUG 25 2021 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARiON COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# UiLDING INSPECTION <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> • <br /> A Property Owner Information <br /> .,- <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description ` - <br /> • <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> c--Wyy k0( . 'cam <br /> Property Address L..ty 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 S Single Family Residence ❑Public _ <br /> 5 Name <br /> Number of Bedrooms Number of Bedrooms p Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> rig Construction Permit El Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation El Personal Hardship <br /> El Alteration Permit El Record Review El Temporary Housing <br /> El Major El Minor El Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> e6°:"(\'e,\ NC 641) 9id A% <br /> Applicant's Name—Please Print Legibly pplicant's Phone Number DEQ Lie.# (if applicable) <br /> A is ilin dress <br /> 5I,.)4 Lig --S--1 <br /> Signature Date: to! CCB# (if applicable) <br /> Applicant is the El Owner '"Authorized Representative El Authorization to Apply form Attached <br />