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071. Ui1-1 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> — :� Wastewater Treatment System city of <br /> MARIONDate Received <br /> ® E C E V I <br /> COUNTY PUBLIC WORKS Received by D <br /> BUILDING INSPECTION DIVISION Zoning by ,a <br /> 5155 Silverton Rd NE Fee AUG 18 2021 <br /> Salem OR 97305 Receipt# MARI DN COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDIN G INSPECTION <br /> www.co.marion.or.us/PW/Buildin2Insnection <br /> .MSE A taett Dar InfortnattnESMEEM ...... ....... <br /> ./I? 4 Cold, 120 %s€rbh , - 6�� s. ��' 91-321 5®3-WrP-2.33® <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> , «: <br /> 013*26Gw3�o© )�1i trim S�' -- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> ��o �sori'4 0051-7 or- 9�-3z16 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> • t s ....., E C.sExa tit g aeili/Proposed Facility 1 t:Ifi ozruattoll I.R F.s <br /> Existing Facility:• Proposed Facility: Water Supply: � � <br /> l Single FarnAv Residence ® Single Family Residence SPublic C/fy D-i Ga7� <br /> Name <br /> Number of Bedrooms Number of Bedrooms El Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ----- - - -----y y _____ x_-__DwTypAfApplicattonF---- <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> g Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> al Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ 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 /> 109Sar9 <br /> bs�r�► s,L4c. <br /> J c7/I 4c,3-S97- -1-l'f 3�z2 <br /> Applicant's Na e—Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Po 13e2x �1 ,/fi,Il cfz,(7t or. c 3 <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner authorized Representative 0 Authorization to Apply form Attached <br />