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EXPIRED <br /> a l -of l a-3) <br /> Application nlication for Onsite For City Use Only: Date Stamp: <br /> awili <br /> Cityof <br /> Wastewater Treatment Systemc-E Q �_- <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> NOV 1 0 <br /> 2021 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee MARION COU '�lTY <br /> Salem OR 97305 BUILDING INSPECTION' <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# <br /> A.Property Owner Information <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 /> &1D S c `,St I tJu(rN-er <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 0 Single Family Residence ❑Public __ <br /> o( Name of <br /> Number of Bedrooms Number of Bedrooms V Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> n. Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El 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 /> 1� = & bc, OD2 -N.0 aIu- -L9.101? <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> D w -` u 'SPX 1ok c ?1 'i 2 <br /> iigplicant's Mailing Address <br /> \\\\� ) 1 \ qu 551 <br /> nature Date: CCB# (if applicable) <br /> Applicant is the 0 OwnerAuthorized Representative El Authorization to Apply form Attached <br />