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• <br /> 22•- co qt Li-) - PR-my <br /> ,,, ,,,N_ Application for Onsite . For City Use Only: Date Stamp: <br /> "-���v Wastewater Treatment System city of E C E Ii V E • <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS - Received by MAY O �) <br /> BUILDING INSPECTION DIVISION Zoning by 9 2022 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 • <br /> Receipt# RI)ILDINO I.NSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> ww .co.marion.or.us/PW/BuildingInspection Activity# <br /> w <br /> ,A.Propeitr Owner information <br /> Pc...kCiLk \"0.ca._e:S S7(5- (40slGcca u L., A ,.-.- vo- - a\. 01e 0173 � 'So3 S <br /> -430- 803 <br /> Mailing <br /> Name Mail Address City,State,and Zip (Area Code)Phone# <br /> B Legal Propeirt�+Descntion - x <br /> Legal Description Tax Lot Acreage or Lot Size <br /> CA,c..\ c, 44t,`\S .t a i r6 <br /> Subdivision Name Lot • Block <br /> • A�,...,wa\\e•. 02 0i73a 6- <br /> Property Address City State Zip Code - <br /> Directions to Property: - <br /> '.-:'-•;C.:Existiri-g Facilit,L Pro-osed Fac /Waterinformation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> tingle Family Residence 0 Single Family Residence ['Public <br /> 'Ib(kw-. Name <br /> Number of Bedrooms Number of Bedrooms ,['Private w&l'- <br /> • <br /> ❑ Other • ❑ Other Well,Spring,Shared <br /> ..- ' ._� M.... .... 'Ir. r _._._ --,Iti.tiiiiiifApphcation _.__.._a. ., i ,...,._-�.n...t: .�._-..._ ._ <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> E Major. ❑ Minor ❑ Existing System Evaluation El Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 Other El Connecting to an Existing System Never in Use <br /> . (over 5-yrs Old) <br /> El Other-Please Specify <br /> • <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 /> Ltsc-l{e- \A.av-L et'- ' =G1:.ac-Zbc.. 54l-D-5-8-'-t37C•( 3710E <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3aq.-te- • (bce_vn-bcr ia. Ltiea..„ O (Z 617 355- <br /> Applicant's Mailing Address <br /> �' ti- a S- 2a Pttet3 0 • <br /> Signature Date: • CCB# (if applicable) <br /> • <br /> Applicant is the❑Owner Authorized Representative 0 Authorization to Apply form Attached <br /> G:IFORMSISEPTIC\S-01 ONSTI E APPL St.PT 2018.DOCX Rev 1/15,3/18 <br />