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ZI - o0Sil611 - PKmT— <br /> Application for Onsite For City Use Only: Dii E ,-- ate St ❑ <br /> Wastewater Treatment System <br /> City of _ <br /> iii-— -n—.. <br /> Date Received — <br /> 11 <br /> MARION COUNTY PUBLIC WORKS Received by AUG 12 2021 <br /> BUILDING INSPECTION DIVISION Zoning by A <br /> 5155 Silverton Rd NE <br /> MAR ON COUNTY <br /> Fee BUILDING INSPECTION <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildinnlnsaection Activity# <br /> A.Property Owner Information <br /> -_—_ u Sa11na ("0� I1 t RC/re h S} , C a�-P S O e 9'13-i1?e <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> Aa, 'h ri ,� ,�,r� �.� 1?i13 „� . B. Legal Property YDescription <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: I f(c e I ,S 1--r-C e-; <br /> C.Existing Facility/Proposed Facility/Water Information � mF <br /> Existing Facility: Proposed Facility: Water Supply: /^+ <br /> Single Family Residence Single Family Residence (aPublic Cokes C. <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D.Type of Applica 'on <br /> ❑ Site Evaluation ❑ Renewal Permit Authorizati Notice for: <br /> 0 Construction Permit ❑ Permit Reinstatement Repla ' g a Dwelling <br /> -gi:..12.1.4r Permit El Permit Transfer Th ddition of One or More Bedrooms <br /> ajor 2 Minor E Existing System Evaluation 0 onal Hardship <br /> ❑ Alteration Permit ❑ Record Review orary Housing <br /> ❑ Major ❑ Minor ❑ Other Co ecting to an Existing System Never in Use <br /> (ov -yrs old) <br /> ❑ Other— ease 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 /> 1 rrq N€uo+-or1 o3Ag3a— ,?a5l . g 1 1 L) <br /> Applicant'slName—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> l 553 1)Jectew ►.00nel pi_ , 34t- DJ_ q 38 3 <br /> Applicant's Mailing Ad Es <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner yl Authorized Representative ❑ Authorization to Apply form Attached <br /> I <br />