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ur <br /> -ci -PR-t <br /> Application for Onsite For City Use Only: Date Stamp: <br /> .ni �ou,mr <br /> ---�; Wastewater Treatment System City of1111111 <br /> - <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by C <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# JAN 11 2021 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildin¢Inspection Activity# RION C UNTY <br /> A.Property Owner Information BUILDING IN PECTION <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 /> C1S eod' c <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 [kr Single Family Residence OPublic / <br /> Name <br /> .� l�'�'y <br /> Number of Bedrooms Number of Bedrooms IR Private <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 /> 21. Major ❑ Minor ❑ Existing System Evaluation El 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 /> ?)L'1/4\0e(T:K033C'\ 8c5b ,ub a'A--lb 641c15 <br /> Applicant's Name—Please Print Legib Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Pb doX 5134 —flirr—, 0(2 `'1-1 .a <br /> Applicant's Mailing Address <br /> gt-'1551 <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative ❑Authorization to Apply form Attached <br />