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t <br /> 0,21 -DC) 36;-41 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received [D--i C J f rl\ 'E <br /> MIMI MARION COUNTY PUBLIC WORKS Received by L U <br /> BUILDING INSPECTION DIVISION Zoning by M\R 312021 -- <br /> 5155 Silverton Rd NE <br /> 1-'bi) <br /> Salem OR 97305 Fee MArii�� COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# UILD, G INSPECTIO <br /> www.co.marion.or.us/PWBuiidinglnspection Activity# <br /> A.Property Owner Information <br /> cZU :1---N6EAAdi<Ve2 3!coj 2 Vk c-edM) A &a-ce.I OP, 97 3V a17- c62- Mar <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> oci 5 . 2s" Lc 0 3co00 <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: 3 6o$Z 17--A-1,t_-O oeiN Pr/6 t (ems /C c. CR. l-k Wy ZZ <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single F.ai ily Residence kJ Single Family Residence ❑Public <br /> c— Name <br /> Number of Bedrooms Number of Bedrooms ,l Private <br /> ❑ Other ❑ Other ell rm Shared <br /> �P g� <br /> __ D.Type of Application <br /> .❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement X1 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 4:;42- ITS i 7- ,5.Z--29v,- <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> ._3-3/— 20Z / <br /> attire Date: CCB# (if applicable) <br /> Applicant is the,Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br /> L <br />