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Application for Onsite For City Use Only: Date Stamp: <br /> ------ Wastewater Treatment System ' City of <br /> Date Received (� <br /> MARION COUNTY PUBLIC WORKS Received by \-_A L�J n <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MAR 3 12021 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION C.-Oc Mr'T'lf' <br /> www.co.marion.onus/PW/Buildinginsnection Activity# BUILDING IN ,r N <br /> It A Pro er Owner 1nformatzang <br /> frn: geido $afJi5f Cinadi PO t3atc //4S ,NI illCJ ,E2t �? �® S®3 .2.77 35N‘ <br /> Name • Mailing Address City nd Zi=p (Area Code)Phone# <br /> . „ NE ..� �..... . . ,- , .... 13 Legal Properly Descnptac n, u.,, .- fi$.r .5„` ... .-. <br /> t <br /> �......,p43Ea6cc.0 3�1 2_6. <br /> Legal Description Tax Lot • Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> .3 Z- ����r� S'C, o.,leS or 9-7.3 y 6 <br /> Property Address City JJ State. Zip Code <br /> Directions to Property: From -.Z 2 5oci , 0n Sarbii� 1 5.5+4c? 1 ,z,e 1#r/ 1iir 6l' .. .• <br /> iam000msommmmsxcmtataildAitfogodAalttkikNgwbatNtyowsmommttuzgommcima`` <br /> Existing Facility: Proposed Facility: Water Supply: " <br /> ['Single Family Residence ❑ Single Family Residence MPublic �'t <br /> Name <br /> Number of Bedrooms Number of Bedrooms <br /> / ❑ P rnate <br /> pf Other ..... a Other Gtrolk jkii, Well,Spring,Shared <br /> - -IIEIIIIIIEWRPIEWlgaBkIMWREWIIMgOagaiakAkihhBIEEEEIEEgkgllaag112nniaEEISgIEE112nll <br /> M. Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit - ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ 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 /> P�0 s , s, GLc e 5 el)3—gyp-`ryVS' 392.2_7- <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Appli---cant's Mailing Address <br /> —'--- ger" CO3/2-5/2-459..2. ( <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner ,►; Authorized Representative Authorization to Apply form Attached <br /> r� <br />