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c <br /> EXPIRED <br /> Application for Onsite For City Use Only: a,—000 6 (D sbmp: <br /> ; Wastewater Treatment System city of r Irk , r7 r r !TN <br /> Mill <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by } ' <br /> BUILDING INSPECTION DIVISION Zoning by Ui JAN 25 2021 " " j <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> Receipt# <br /> (503)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildineInsnection <br /> A.Property Owner Information <br /> (joqj r r-, ) ) 77U0/ / 7/ G.ov 's a V l' ' �f- (--fg <br /> Name Mailing Address Cqcit-,e,..)-- <br /> State,and Zip (Area Code)Phone# <br /> ' `' ' — ' B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 13 I t c) L t S yA-r S ^7 3 Li'` Property Address 5 a i State Z p Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence 0 Single Family Residence ❑Public <br /> 3 3 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit thorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other El 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 /> t)(L t NC Q H l??2(1 SA 5d 3 -9 7? ---5 ) <br /> Applic is Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ' r 'l Lc) U I, s O S't T Qu 1� k(2)S D-( 3 1 ,;( <br /> Applicant's Mailing Address <br /> ba4a-P 0 C04-'2- 2_/ 5- i _., , <br /> S e Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative 0 Authorization to Apply form Attached <br />