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ow-cosl-kaiLv <br /> Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> 1111 -RCEVED <br /> MI <br /> Date Received <br /> it <br /> MARION COUNTY PUBLIC WORKS Received by U ry <br /> BUILDING INSPECTION DIVISION Zoning by Jl 1N 1 ery 2022 <br /> 5155 Silverton Rd NE <br /> Fee <br /> Salem OR 97305 <br /> ... ' <br /> MARIONBUILDING <br /> COUNTY <br /> 588-5147 Fax(503)588-7948 Receipt# <br /> Activity# <br /> www.co.marion.or.us/PW/BuildingInspection <br /> , A.Property Owner Information , ` S CT C <br /> !DaVict MtI15 La}cotes LA. 5 Ltam,.,OK ct73o 771,3-722 -` E05 <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description: <br /> 063WZ000O®Ll-00 'Z.03 AG <br /> Legal Description Tax Lot Acreage or Lot Size <br /> SLivt vt.(S i cL.e. Rau tT Fart/11. l 4 i <br /> Subdivision Name Lot Block <br /> 63(0.8B L.ako-f - Lase_ 5 sal.Q.w.. OR G 730Co <br /> Property Address City State (� 'Zip Code <br /> Directions to Property: � a( ; dcI j��S`"13 7 6 ( . aCKJ <br /> C.Existing.Facility/;Proposed facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence Jo Single Family Residence ❑Public <br /> 3 %2— Name <br /> Number of Bedrooms Number of Bedrooms X Private Well <br /> e1 I <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> ' _. D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> C Construction Permit ❑ Permit Reinstatement Er Replacing a Dwelling <br /> [r Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> X..Alteration Per t ❑ Record Review ❑ Temporary Housing <br /> ❑ Major Minor 0 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 /> Departmen f Environmental uality,permission to enter onto the above described property for the sole purpose of this application. <br /> f.,a, • 7 75-722 - 5 <br /> pplicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 5D2CP g'LQL-1) a-i 5E , a .v+'\ , OK <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑ Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />