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aa-fib a 9 R-7 <br /> Application for Onsite Date S <br /> PP For City Ilse Only: P: <br /> --1- Wastewater Treatment System City ofIIIIIII <br /> Date Received_. <br /> MARION COUNTY PUBLIC WORKS Receivedby ® 'i f y <br /> BUILDING INSPECTION DIVISION Zoning.by ___ <br /> 515S Silverto�r Rd NE 7... r- <br /> ,.. .....,,I., _ , <br /> Salem OR 97305 Fee m APR 0 8 2022 <br /> e2- <br /> (503)588-5147 Fax(503)588-7948 Receipt tl <br /> www.vo.marion.or.us/PW/Buildinalnsnection Activity# Mk._. 'W k-s d'l <br /> BJILD-ii.,a INSPECT10f\ <br /> P�/*- <br /> Sta-V L. A cLe-G�'- 3 7.308 / �-e L ` L R 9, 35,s s41-qco-Eggett <br /> Name Mailing Addres C City,State,and Zip (Area Code)Phonelt <br /> B.Legal Property Description <br /> w- S elo Cb`}oo i ..5 -- . <br /> Legal Description Tax Lot Acreage or Lot Size <br /> LA-L ACte °t <br /> Subdivision Name Lot. Block <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> t tit , ti ct a ttg ; t. Qt iWAR Y <br /> Fisting Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 'vp Single Family Residence ❑Public <br /> i M Name <br /> Number of Bcdr oms Number of Bedrooms (Private 0+" w►.e:r t.+bo t:., lc,k- <br /> ❑ Other 0 Other Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation 0 R• enewal Permit ❑Authorrration Notice:for: <br /> Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> Repair Permit ❑ P• ermit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ M• ajor 0 Minor ❑ .Existing System Evaluation 0 Personal Hardship <br /> Cj Alteration Permit ❑ R• ecord-Review 0 Temporary Housing <br /> ❑ M• ajor 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 and attachments are not included with this application.it will be returned 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 ofthis application. <br /> (Zocl- :11i\\ excASk-c...4;h 5N1-09-.;g'ir34 3100ct <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number .DEQ°L:ic.# .(rf applicable) <br /> 3 7M t cc o-N-\- e.0 L.-cb.,.a.., ock of l W <br /> Applicant's Mailing Address <br /> Signature - Date: CCB# (if applicable) <br /> Applicant is the 0 Owner ►o Authorized Representative 0 Authorization to Apply form Attached <br />