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021-6bLiLfiQt a <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of <br /> l "i Date Received RECEVE ---- <br /> MEM <br /> MARION COUNTY PUBLIC WORKS Received by11 BUILDING INSPECTION DIVISION Zoning by j MAY 052021 <br /> 5155 Silverton Rd NE Fee IVI i I d I COUNTY <br /> Salem OR 97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> t'.,.. - u ; _xi .� ,s ,,.-..__.� �� _Ay Property:Owner In}oriahone r. w �.,�,.�,.�..=o.�_.r ¢.0_ �.�w�. _ _.y.y __,f. <br /> Jo-cob j KAA,Uf 05-76-- Kewpmad► F►dNL StivW • oS er73t ( so3-Tao-IaSs- <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> x x B Le a1'Pro a Desch tion` 4 ' a ` <br /> 3. c -i <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 4D <br /> Subdivision Name Lot Block <br /> 336 5-5-4AN A , - sa (to o cc R 73°5— <br /> Property Address City State Zip Code <br /> Directions to Property: Ime-aA (C> 1A, °Y• . A tioSs, -24. <br /> ik cl. r C ir- 'wl w,- ,Ai -4fn •-bav t- w Vz it'd l.c 1 1 ro fsc..la %S are c J ;o l r- ('tq A.1 <br /> l <br /> , ,>_ _ �Y t n�C Ex stmg;Factlity I Proposed Facility/_Water Info marion ry K, P,. .f _. _ ,,,Y _f_ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> (Single Family Residence NI Single Family Residence ❑Public <br /> Li Name "� <br /> Number of Bedrooms Number of Bedrooms ❑ Private 6�nrrKa- (,✓P.1l <br /> 0 Other ❑ Other Well,Spring, <br /> Shared <br /> r T ype D offApphcahon lgM�. y .' <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> 0 Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> txt0 Major 0 M• inor 0 Existing System Evaluation ❑ Personal Hardship <br /> Alt ration Permit ❑ Record Review ❑ Temporary Housing <br /> ' Major 0 M• inor ❑ Other 0 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, 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 /> r c.L.D\40 (\,\ve,\,\(✓ s()- 1 a a 1 t'W /V/A <br /> Applicant's Name—,Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 1,0S7S ``tkaJ%-itut,A INS A)E / r c L\ L)I\ Q /7sei <br /> Applicant's Mailing Address <br /> # • ` V CGJ -5-_ Zl <br /> Si ,ture Date: 0 CCB# (if applicable) <br /> Applicant is the(TI,Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />