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EXPIRED <br /> 2/s_OOO /--%-0Tt/ <br /> r .,, Application for Onsite For City Use Only: Date Stamp: <br /> — Wastewater Treatment System city of � 1 „ 1� <br /> y Date Received L J �� J ` <br /> Received by J <br /> 111111 MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION Zoning by JAN 1 2 2021 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION C DUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INE PECTION <br /> www.co.marion.or.us/PW/Buildinalnsnection Activity# <br /> A.Property Owner Information '3 i' <br /> '.u�.0 '� 1 g w , Alkikv,. <br /> Ta.wk kNckss,- as lc, 6),c R„, s- \-e Wp - e?317 30;-7/o-/650 <br /> Name Mailing Address City,State,and Zip (Area,Code)Phone# <br /> i B.Legal Property Description 3 � � <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 5-66t7 L;A.,.wooel r C 6...k<s 00- 7 7 3yi <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information r -. .ru <br /> s�ardpirsmdC�n�s�e:.*ra-ov :r 5 s <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 15gSingle Family Residence 0 Single Family Residence gPublic <br /> VI esi- Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> O Other El Other Well,Spring,Shared <br /> .>:w, D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement E. Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> O Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> O Alteration Permit 0 Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> ,..h SAa5Y crlCknefyl G rk,bsKd 5-03 -9/0- iO3-17 oOL 7R?Li 3 <br /> Applicant' . . ' : Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 49-S1 . 6a)' ff.,t se m. (fit °I7 31-7 <br /> Applicant's i ailin, . dress <br /> -. th.pi) <br /> Signature Date: CCB# (if applicable) <br /> Applicant is thel.Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />