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2 __. O a v yo — Ae-444 ( <br /> Application for Onsite For City Use Only: Date Stam <br /> „�,_ Wastewater Treatment System City Date oReceived f <br /> ���� E ( E WE ' <br /> .. MI <br /> Received by r� <br /> MARION COUNTY PUBLIC WORKS MAY 16 2022 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton.Rd NE Fee MARION COUNTY <br /> Salem OR 97305 BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or•.us/PWBuildinsInsuection Activity# <br /> c. a "`'+iq'. P r5s"*.r' a "' A �7sm id - .� a.1;r" .µ:' <br /> +�"' f� tS .� � � i � +x # a,. .�' '' ly..NiA� � ..� k �� n'� <br /> \ Javrit5 i 2)1 rsytm{r Cult Ur `t rn 01L crPon 5oS-139-551 s <br /> Name Mailing Address City,State,and Zi (Area Code)�� Phone# <br /> .. ..� i f ' A• . •j."'...,e§@ 7 .�k1k F Y d a t%1°E}NP:p t'Y.'` �a X .. C� 9w; ,.• <br /> ° ,,,,,„ 40 }{ ,��.. i .s k tUt 'a { ,,J""�a A�.�- r, �Y'+ 1 A r..�" )may,�{ t <br /> ,m»,k ��.�r�i� 3•;?� e T'' I�1 .r,�III�. , .'� y w+r ;«�i .. IF�i��AY ?tttzl ��D7� at."� r � ra <br /> Legal Description ' Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> t j31 Yr-(.b(6A\e ¶:)r SE Sals<.vy., � on31- <br /> Property Address City State Zip Code <br /> • <br /> Directions to Property: <br /> �:. k'q". l..ems{ 6, cr.�. cr,740w' 4 �, 1 �_ 5�{ . '•FF�' rth.($. 7�' a'n"5E ,:wva T-1 i•t'9 <br /> ✓3� ._,. ,YG d..vir.�ia � � i •i;.. �:Y �{�°���—0��.. g @•o a :�`5`'�� xc�f�-':fiex,��vr�:�+�.iiaw..x�V .a"i@�rs'�3�K� 'hu4� M�:��"' 3' <br /> Existing Facility: Proposed Facility: Water Supply: <br /> gingle Family Residence ❑ Single Family Residence ['Public-L Name <br /> Number of Bedrooms Number of Bedrooms p Private UV�2,1 <br /> 0 Other 0 Other Well,Spring, Shared <br /> ❑ Site Evaluation • ❑ Renewal Permit ❑Authorization Notice for: <br /> ' ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling .. <br /> lgt R air Permit ❑ Permit Transfer ElThe Addition of One or More Bedrooms <br /> 0 Major in Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Pe II't ❑ Record Review ❑ Temporary Housing <br /> El Major ❑ Minor El Other 0 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 /> •'PSC , 5 e plc- 501D-'2012r Iz253 3301- <br /> Applicant's Name-lease Print Legibly Applicant's Phone Number DEQ Lie,# (if applicable) <br /> Vo t.ox (210 1 1b oou—S O2 °r ,c . <br /> Applicant's Mailing A dress . <br /> ` ii�� -- anticSiaa'440 <br /> ture Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative ip Authorization to Apply form Attached <br /> 1 <br />