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i <br /> Application for Onsite i d—�L �S c1 � '_ ` ' '. <br /> w' For City Use Only: Dare Stamp: <br /> - ,. Wastewater Treatment System City of <br /> Mt/ Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by k5 _ V E 5155 Silverton Rd NE Fee p <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# SEP 3( 2021 <br /> www.co.marion.or.us1PW/BuildingInspection Activity tt <br /> WARION QOUNTY <br /> A.Property Owner Information BUILDING INSPECTION <br /> SAnd.i 1wood 2-7 e�me-i- Sob\k • <br /> mn t CR 973g5 503 % <br /> 1 Name Mailing Address " ) -e) I- e# a to <br /> b City,State,and Zip (Area Cade)Phone# <br /> B.Legal Property Description <br /> ACCoO,k it 3t I tp6 oc8Mit135 c x5O(3 Q. 0-7 Acre c <br /> , <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> -7gg1 13oeAic \ r Rd O;mA.1 __ _ 9-73gs <br /> Property Address _ City State Zip Code <br /> Directions to Property: CD't+fxe.C' �ix- `RA St 3 13r>e.kirp,e't,",.t° e" Rck SP <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Dingle Family Residence(w%\\ 'oe Qingte Family Residence ❑Public <br /> -1-04-rN 4 Name <br /> Number of Bedrooms d ` � Number of Bedrooms ! tom' rivate WC I <br /> ❑ Other [Other 'Re(J\&Cew\an\ ` J.l r Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ` 0 Renewal Permit 3.Althorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 'Ai.-Replacing a Dwelling <br /> Cl Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor El Existing System Evaluation Li Personal Hardship <br /> I. 'Mteration Permit,. ❑ Record Review ❑ Temporary Housing <br /> [ <br /> 0 Major Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> over 5-yrs old) <br /> Other—Please Specify ALAN,. do .rAelck. <br /> \.tire <br /> if the required fee and attachments ar or inc ded with this application, it will be returned to you a 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 /> '"ede__, r;s �tti,N3okc =i. <br /> -- ce_v-sc . 03- (.0 '3--- , 391 to 7 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ZOX. 1 t.5_R„ 2YS <br /> Applicant's Mailing Address <br /> . --_� 9- g?- a) 158�y3 <br /> Signature Date: CCB# (if applicable) <br /> r <br /> IApplicant is the❑Owner Authorized Representative [authorization to Apply form Attached <br /> sec c ed , <br /> AUakce ce.v-t v1 ,^5 . ' :, <br />