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N Application for (UP I EDniy: D mt.[ E n <br /> ..., <br /> - - _ Wastewater Treatment System City of <br /> 11 <br /> Date Received 11111 - <br /> MARION COUNTY PUBLIC WORKS Received by JA N 0 S 2021 c� <br /> BUILDING INSPECTION DIVISION Zoning by IViARION COUNTY <br /> 5155 Silverton Rd NE Fee BUILDIN,,G INSPECTION <br /> Salem OR 97305(503)588-5147 Fax(503)588-7948 Receipt# 7s(15�� <br /> m 3 ion.o 1s P A Bui.tl f„ - _ iou Activity# <br /> A. Property Owner Information <br /> ni7 &I -907 & //bir0d y � en4 , O 173e 93-7794 $ <br /> Mailing Address S � <br /> Name I City.State,and Zip (Area Code)Phone# <br /> B. Legal Property Description <br /> Og.2-E22ZC90 f30o t ), e > <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> c qc 5��-hU4�� /6drk i(d s /dam �/ 97.7 -e <br /> Property Address City 'l/ State Zip Code <br /> /� i <br /> r'! i st of rlL <br /> Directions to Property: ® �� i" .fit y �Pr1Y'� �� � ,� BSI d7'1�'!lk <br /> P Y L� o? � 6 l .� � !l. <br /> �y�, / y J <br /> C.Existing Facility 1 Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ❑ Single Family Residence ❑Public <br /> 2 3 Name <br /> Number of Bedrooms Number of Bedroomsrivate <br /> 0 Other 0 Other Well, ring,Shared <br /> D.Type of Application <br /> r: <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authon for: <br /> Notice o . <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Re..'r Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> is Major ❑ Minor ❑ Existing System Evaluation 0 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 /> . o ( ) 77e14zc® <br /> Applicant's Name-Please Pri Legibly Applicant's Phone Number DEQ Lic. # (if applicable) <br /> 5 0 75" 8/7/4",4ivle Oa/ S. / .St ' e,04 19/2 G76' <br /> Applicant's Mailing Ad ss <br /> , ,- ,/ �,) 1 . / 06:-2—/ <br /> Sig Mature Date: CCB# (if applicable) <br /> re <br /> Applicant is the Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br />