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L <br /> .,,0 ,,„„,, Application for Onsite . For City Use Only: Date Stamp: <br /> — =; Wastewater Treatment System City of - —� <br /> . .: ® EC F �V <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS - Received by <br /> BUILDING INSPECTION DIVISION Zoning by MAR 1 2022 ,-- <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 - MARION COUNTY <br /> - (503)588-5147 Fax(503)588-7948 Receipt# BUILDIN G INSPECTION <br /> • <br /> www.co.marion.or.us/PW/BuildingInspection Activity# <br /> t'_f'Grl!cr. t�-0-In ' SLL _`._.__A.Pro�eOwnerTnforlmation <br /> 4;5 t( F \U1/ 6101 99 .. ,acOn leaf) VUE Jf�+.e"2, Or, rl'73(n'- 6-.63') ??.1,7200 <br /> Name 1 _ Mailing Address City,State,and Zip (Area Code)Phone# <br /> ____ . B.Legal_ProportyDescrtptiou • <br /> —_._._. <br /> Legal Description ( L [ Tax Lot Acreage or Lot Size <br /> n <br /> • <br /> Subdivision m Name Lot - JB�locck <br /> MO I.7u1/G 51 ! _ -k o`rL` c--.61k\rc` (..�_ <br /> Property Address City State Zip Code • <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> 0 Single F 'ly Residence Single Family Residence DPublic <br /> 2 Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well,Spring,Shared <br /> D.Type of Application <br /> RSite Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement - ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 181 Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> _ (over 5-yrs old) <br /> 0 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 /> �4I ;.�,,,t lib 14,,es. �.LCI s?3— 71 —roUO RI 7c9 37762 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> I <br /> 7/6 1 .��'�6 I I e let,. Rdt, V E . S Icw, 0,,,. `mil 'O3 <br /> Applicant's Mailing Address <br /> 6.---' fHtL ►C, 202_ , 21 3gI - <br /> Signature Date: CCB# (if applicable) <br /> • <br /> 11 Applicant is the❑Owner authorized Representative ❑Authorization to Apply form Attached <br /> G:\FORMS\.SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br /> l.J <br />