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r <br /> —00362a-� , <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> 1 <br /> Date Received MECELIVEID <br /> MIII MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by MAR 312021 -- <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee ���DN ��U <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILD1�G INSPECTION <br /> ww.co.marion.or.us/PWBuildingInspection Activity# <br /> w <br /> A.Property Owner Information <br /> cZo -r 4A6emo-Vero— 3 2Cojj 2 c 2c Am &ill O 973V, a/7-S3z- Z9O6 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 0ct5e. Ls"rc 03toO0 <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: , 108 Z T--A,l_�k-fl /n// , (. S /c c- c t-k W y ZZ, <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Fargily Residence ,� Single Family Residence ['Publice�_'FJ Name <br /> Number of Bedrooms Number of Bedrooms ,g Private <br /> ❑ Other 0 Other rin <br /> �•P g,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement XI 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 /> ?�—�rs 7- 5 2--•2?Of <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 /> ature Date: CCB# (if applicable) <br /> Applicant is the,Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />