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c O ) bl-A. <br /> Application for Onsite For City Use Only: Date stamp: <br /> Wastewater Treatment System City of ' <br /> qLEC-EFLIWI'F_, <br /> MARION COUNTY PUBLIC WORKS Date Received <br /> Received by <br /> BUILDING INSPECTION DIVISION Zoning by JAN 07 2022 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildinQlnspection Activity# <br /> cc A.Property Owner Information <br /> -I, /nzuS 405 26-/- S/- ski-1_ 0E47301 .63-130-3733 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal ro erty Description <br /> (3q1 w c20 DOo09OQ j_ Z2 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1 a W3 siiew-I Z 7 3E 7�knf Qom- 1,739 2 <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 /> Family Residence 0 Single Family Residence :Public <br /> X.S..ingle <br /> a_ Name <br /> Number of Bedrooms Number of Bedrooms Private 1/V l f <br /> O Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit [fA thorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement %J Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation ❑ P• ersonal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ T• emporary 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 /> Dep t of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> av�n al/nal/03 c-isU. 33 � <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 90 � 2G S4- Ge__ q730/ <br /> Applic s Mailing Address <br /> a))fi / - 7- 2dzZ <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />