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44111110.. As Application for Onsite For City Use Only: Date Stamp: <br /> _ Wastewater Treatment System city of D <br /> E �j S I V <br /> MI MARION COUNTY PUBLIC WORKS Received by J l D <br /> Date Received <br /> BUILDING INSPECTION DIVISION Zoning by AR 212019 <br /> ION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MA-.ION COUNTY <br /> SUILD NG INSPECT <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildinQlnspection Activity# <br /> A.Property Owner Information <br /> Lin llxim,5 7 36,25- kc.51,0-/.. 1. ,5E c.(a,/C 435a <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> fej,tt t 3 P-rl,,.. 171.,4- 2 -c2( <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 2�sF 2e.. v.-€4,..i i_iiL s S,-,_te.w. CY2 q-13O,Z <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 pt Single Family Residence ❑Public <br /> q Name <br /> Number of Bedrooms Number of Bedrooms Private Wet/ <br /> 0 Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> 15 Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review El Temporary Housing <br /> ❑ Major 1:1Minor ❑ 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 /> (3 ,i,_ Scti,,rc. d-! -t_ L1.1_, So-3.-6-74-e---.'i4-1/4-7 Zgl 6 <br /> Appli is Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> fC;2 ( 12€--z_ ,`-i,),Sf a� c / -l1 <br /> Applicant's Mailing ddress <br /> 3-Zc,-- (ek �0I 8- <br /> 3 <br /> Si re Date: CCB# (if applicable) <br /> Applicant is the 0 Owner la Authorized Representative Authorization to Apply form Attached <br />