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61c_ 4L) -k-toci-- 9-ek ReAgey+ C.T, 0.71-DD5 aBa <br /> Application for Onsite <br /> IN. pp For City Use Only: Date Stamp: <br /> - Wastewater Treatment System City of <br /> REEIVED <br /> Date Received <br /> Received b <br /> MARION COUNTY PUBLIC WORKS y <br /> BUILDING INSPECTION DIVISION Zoning by M AR 3 0 2021 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDI VG INSPECTION <br /> www.co.marion.or.us/PW/Buildinelnsaection Activity# <br /> A.Property Owner Information <br /> PZpt o- , Lic I.2-I® SW&wcnontsf- foo f'l� or, , -Z.2S 563- 1? ) <br /> Name Mailing Address City, State.and Zip (Area Code)Phone# <br /> B. Legal Property Description „ <br /> �yA3.2 epo/3�; -S 1 ies <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Rans6//Ls A//<J 1 5..4 Iv - `3 Z <br /> Subdivision Name Lot Block <br /> 3536li Frond k 'Sf- SE ilo25 ©r- `77.3 <br /> Property Address City State Zip Code <br /> Directions to Property:.g,,¢©n ./1',ii,rk R, an E/khIn , rSE, 3r ' 4 lr_(. o ,e, 11- <br /> C. Existing Facility/Proposed Facility/ Water Information <br /> Existing Facility: ,bLt yy)ed Proposed Facility: Water Supply: <br /> j2<ingle Family Residence `RI Single Family Residence ❑Public <br /> 3 3 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private we-if <br /> tyfOther ,ynos71----5%� ❑ Other Well, Spring, Shared <br /> D.Type of Application <br /> n ❑ Renewal Permitu horization Notice for: <br /> Construction Permit ❑ Permit Reinstatement Replacing a Dwelling <br /> R air Permit ❑ Permit Transfer The Addition of One or More Bedrooms <br /> ajor ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> 0 Major El Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> +QVl l - Qvl d a br1r�l e `C� ❑ 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 /> Afferi Scfiv,c-ws) J.C. S(1)3-3f -HgyS -39.22� <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Po .Box Sl f,I/c',: cr, 9-73C& <br /> Applicant's Mailing Address <br /> ---- ‘'(}/Jr-- - er.72 ,.--9/7---IV.2-I <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ®Authorization to Apply form Attached <br />