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EXPIRED Ic\--tbra-5C4 <br /> Application for Onsite CityOnly: <br /> For Use Date Stamp: <br /> City of <br /> mgWastewater Treatment System nE 7Date Received D <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by MAR 29 2019 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <br /> )70 up/x 0 wiis5lOr1 ,g4-1C EaI(lerreek Sa/e04 a, '?t7/7 f ,363 S"L38 <br /> Name Mailing Address City,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 /> 644/4, Ba �-f rCrt� C � <br /> k Sed(kin - 9 7>/ 7 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 'Single Family Residence ❑ Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms a Private tA..2J i f <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> a ❑ Major ❑ Minor ❑ Existing System Evaluation Personal Hardship <br /> ❑Alt- .tion Permit ❑ Record Review ❑ Temporary Housing <br /> i 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 /> 9( e , 3 (_r 563 gc1'( /S3 yes" 5NApplicant's Name—P(rot <br /> asel Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> P, 0 . 50/ Z/l 5-0 /6: e- ,.,-- a• 7c 7 <br /> Appli 's ai ' g Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner gr Authorized Representative 0 Authorization to Apply form Attached <br />