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Ici -0011136 - <br /> Application for Onsite For City Use Only: Date Stamp: <br /> '------%%---->'=-.1 WWastewater Treatment System city of L� <br /> ' EllMARION <br /> Received s <br /> MARION COUNTY PUBLIC WORKS Received by JJ <br /> BUILDING INSPECTION DIVISION Zoning by JUN 04 2019 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 t MARION COUNTY <br /> Receipt# <br /> (503)588-5147 Fax(503)588-7948 P BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> $ cT F g - A Pro W4 er TOaa 10 N a W:WM2W <br /> �i41Mt03 1. i skey /50 l w1llcin 4)' , <br /> l4 S'L 1 ) if% GYe '/1385- S bas's ' 73-- .2z07 <br /> Name / Mailing Address •City, State,and Zip! (Area Code)Phone# <br /> iV <`Y 's. 5-a L Y:. al`Pr e esCi1 tll fie` u ' T xW. :F a OZ{ <br /> Legal Description Tax Lot Acreage or Lot Size Z/d Co q <br /> Subdivision Name Lot Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> F4 F t° % DZ:t ini :#ig. trl,j asear42R5f aaer fnfarmation ie aix <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence 121,Single Family Residence ['Public <br /> 3 +2_ ` ,5-• ? Name <br /> Number of Bedrooms Number of Bedrooms Z Private <br /> O Other 0 Other Well pring, Shared <br /> y aa3ZT' ego* llcailon jt L A <br /> ❑ Site Evaluation ❑ Renewal Permit KlAuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer S The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation DI 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address,/ <br /> #aPkiiJL'41 /I I `�`r� D <br /> .tune r 0 Date: CCB# (if applicable) <br /> Applicant is the❑Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> P /1/I t i s Wec7 0 i -C. e <br />