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• 0 <br /> • <br /> c 2 rcg?— <br /> ,t�'` Application for Onsite For City Use Only: Date Stamp: <br /> City of <br /> um <br /> -- ==_% Wastewater Treatment System <br /> Date Received Ell LD <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee JUL 01 2022 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt II MARION COUNT` <br /> www.co.marion.or.us/PWBuildineInspection Activity# SUILDING INSpECiliON <br /> A.Property Owner Information <br /> b25 0VZ q 757 <br /> j 4 amoM 6,u,r µ.vc.„' Mailing Address City,State,and Zip (Area Code)Phone# <br /> <•0 K F— t K( - B.Legal Property Description <br /> e) 83141l3D ) OO <br /> Legal Description �— Tax Lot Acreage or Lot Size <br /> 7a,a5(e W000l (S A A /VA/a 2 for I gi°` k 9 <br /> Subdivision Name Lot Block <br /> S 5 / S ,Scve S i t%( Of,v, S Sc A fir( '7 3 0 7 <br /> Property Address _ City State Zip Code <br /> Directions to Property: S 5 ( 5 S f 1e to 11 r Or 1 s <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single ""Residence `�J Single F' i Residence Public <br /> I Name <br /> Number of Bedrooms Number IT Tearooms ❑ Private <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 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 /> cbo(50 v i Jock--50 I 1pfe•sioikr 5 49 S 5 5 I 0 171 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> J.tz k Owtmteve,,,1 C.v51 <br /> I°c' t `77( 3`i I Z C4cw, c22 1 75oz- <br /> Applicant's Mailing Address <br /> 14 Pt. i/6sh't ?,(—ZZ l (Oze76 <br /> Signature Date: CCB#/ (if applicable) <br /> Applicant is the 0 Owner Authorized Representative 0 Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS1 SEPTIC S-01 ON ITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />