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as- ba1a5 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ---- Wastewater Treatment System City of <br /> Date Received �V <br /> Received by ® I C'P i' f, <br /> MARION COUNTY PUBLIC WORKSi <br /> BUILDING INSPECTION DIVISION Zoning by 11 <br /> ,._,J <br /> 5155 Silverton Rd NE Fee b MAR 3 0 2022 ' <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt it MAR I O i u COUNTY <br /> www.co.marion.or.us/PWtBuildinelnspection Activity# BUILDING INSPECTION <br /> A.Property Owner Information <br /> s #-Jrzwk. rkiti, li-i60 fa'trewraa&tc..r s—t 'Ts'.a;.-e.Lr C'12 ee-72.24( <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 /> 611.53 IU Ey-L.: 44.1 se 1 yc 5 C. . ci-7 3S,8' <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 rN Single Family Residence OPublic <br /> 5C- !1 (42) ��+ .5 Name <br /> Number of Bedrooms �? Number of Bedrooms tg. Private ArI-- Yam• '-, t Elea( <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> ►;l Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> CO Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> 0 Alteration Permit ❑ Record Review 0 Temporary Housing <br /> 0 Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> * S Yt3}C W't f2eSho lers( t t-. g rt t /ei+ R 15 ❑ Other—Please Specify <br /> If the required fee and attachments are not included with this appli on.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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lie.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 <br /> Applicant's 'i dress <br /> 3---30,.. .2._ 201683 <br /> ature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative ' j Authorization to Apply form Attached <br />