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X.- Application for •t ,. ii i <br /> ' : D etrE 0 <br /> ,�� e O <br /> -IIIN <br /> Wastewater Treatment System Ci of <br /> Date Received <br /> Received by -. �ti S 2021 <br /> MARION COUNTY PUBLIC WORKS 'CI <br /> c7 <br /> BUILDING INSPECTION DIVLSION Zoning by ARI }�f (;�(�� <br /> 5155 Silverton Rd NE Fee ���� �Ca INSPECTION <br /> Salem OR 97305 Z 1---( Z <br /> (503)588-5147 Fax(503)588-7948 Receipt# 2:2— <br /> w.en.mariort.o _usiPNVI?E uild roinso tion Activity# <br /> A.Property Owner Information <br /> i s / -91275— gra4bi/Veci kAy5 6116,0 , a,,e im‘P .593-7794015- <br /> Name Mailing Address I City,State,and Zip (Area Code)Phone# <br /> B.Legal Pm erty Description <br /> oq .52.zCcOoe00 /. Eg� k <br /> Legal Description Tax Lot Acreage or Lot Size <br /> J <br /> Subdivision Name Lot Block <br /> 2 C29�,-61‘411:iii i44 , 4,,�k got _ irm m 97.75--t9 <br /> Property Address City / State Zip Code <br /> Directions to Property: L p.r ,4t 2Z 1 :FP? 'Ike en _54,7 0t P J , e f ea r Mil Milerk s <br /> ect <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> jiSingle Family Residence 0 Single Family Residence ❑Public <br /> ,2 3 Name <br /> Number of Bedrooms Number of Bedrooms jj`Private <br /> ❑ Other ❑ Other Well, ring,Shared <br /> D.Type of Application <br /> • <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> 61 Re.." Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> i-2 Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) • <br /> 0 Other—Please Specify • <br /> If the required fee and attachments are not included with this application, ii 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 /> d ( m-47c <br /> Applicant's Name—Please ' Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3 b 2 rfi/ d 4%y C. ,. � ae 'MI6 <br /> Appy is Mailing Ad ss / <br /> age, <br /> S' tore Date: CCB# (if applicable) <br /> A <br /> Applicant is the Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br />