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;71-111ELgt&L\, <br /> • <br /> Application for Onsite For City Use Only: RICEMEn <br /> Wastewater Treatment System City of <br /> Date Received <br /> �- MARION COUNTY PUBLIC WORKS Received by A iG 2�° 1011 Ty <br /> BUILDING INSPECTION DIVISION Zoning by, MAR ON COL/ 1 <br /> 5155 Silverton Rd NE Fee BUIL®j ;ow <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildin2Inspection Activity# <br /> �.. .'". .� y A Property Owner In£ornzatzo <br /> Micheal Roantree 23980 Summerhaven Lyons OR 97358 503-949-7699 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> �,3,3 33 ''' B Legal Property Descriptton <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: 23980 Summerhaven Lyons OR 97358 <br /> c-,,i lusting facility/proposed Faczhty/Water Infocmatroty; tg ._ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> I2Single Family Residence ® Single Family Residence ❑Public <br /> 2 2 Name <br /> Number of Bedrooms Number of Bedrooms © Private Well <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> 0 Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> O 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 /> Modine-Construction Inc 503-302-4444 39331 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 5237 Chehalis Dr. N Keizer OR 97303 <br /> Applicant's Mailing Address • <br /> rg �e 2/11/21 226250 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner ®Authorized Representative 0 Authorization to Apply form Attached <br />