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5 CS-- 2,I-O o S�2-- PO/a-0 I <br /> Ss5 -21 -Oo$z.87,- A-0 i H <br /> Application for Onsite For City Use Only: Date Stamp: <br /> � a-w Wi W Treatment System City of <br /> I llDate Received <br /> MARIONastewater COUNTY PUBLIC WORKS Received by D <br /> CEIIWE ---- <br /> , <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee AUG 16 2021 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> HE <br /> www.co.marina.or.as/PW/BuildingInspection Activity MARION COUNTY' <br /> 1i DING INSPECTION <br /> A.Property Owner Information <br /> . <br /> Het vo(c Ef ft5 /(4) t?&-tfk. A.) /.4'0111- OW Z.. <br /> Name Mailing Address City,State,and Zip �'7WZip (Area Code)Phone# <br /> B.Legal Prope' Description; <br /> /a 5 Ec�l ereigz cc 'I <br /> Legal Description Tax Lot Acreage or.Lot Size A <br /> //awl/it/tie/et. / :Qelti , / ci- 16 12 <br /> Subdivision Name Lot /� _-� Cry-y Block <br /> i9J0 Lau' /vp !J�Y1 -e,l Crz ` (-3Liz_ <br /> Property Address City 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 KI Single Family Residence ❑Public <br /> ( Name <br /> Number of Bedrooms Number ott Bedrooms 0 Private <br /> • 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ElAuthorization Notice for: <br /> 0 Construction Permit ❑ Permit Reinstatement ® Replacing a Dwelling bovvvv <br /> Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ►! Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 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 /> Appy t'sName-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Pr) /2o,c loz c lr �' , (a)? 97Z <br /> Applicant's Mailing Address <br /> e Date: CCB# (if applicable) <br /> Applicant is the❑Owner 'authorized Representative TpAuthorization to Apply form Attached. <br /> , <br />