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a 5-e1D-53F\t3 <br /> Application for Onsite <br /> For City Use Only: <br /> ,,.,a__,-, Wastewater Treatment System City of <br /> —Thi — Th <br /> Date Received t _� <br /> MARION COUNTY PUBLIC WORKS Received by MAY 112023 <br /> BUILDING INSPECTION DIVISION Zoning by MAR ON O&JN 3``a <br /> 5155 Silverton Rd NE Fee BUILDING INSPECTin4.1 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww .co.marion.or.us/PW/Buildin2Inspection Activity# <br /> w <br /> ....:A Property owner Information ._ <br /> A Arili0Nr 11 OkO) -' ` P.O (fox Lt3� TdA,v1,A o R Ct13 :603_$4 9-2076 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B•Legal Property-Description:_ -. _._..:: : <br /> 0►e. i 7 0. PCB. ''goo 1-0 o 2.3 g- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> iubdivisiobLE \ I O\1 t� Lot Block <br /> i32. Ci62Gh si- lAAO11A. Ca 617350 <br /> Property Address City State Zip Code <br /> i <br /> Directions to Property: I4 W vA a-2- 40 AA/ A . �i iJ t 0 A) CIA IA a.ck SI <br /> �j 2c*� - <br /> 1 i s /J +h e t e-Pr, <br /> ...._ . . _C Existing Facility/Proposed Facility/Water Information _.-.. . -_ <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence grPublic CA-y e` !1.K/„A <br /> 'r h Name <br /> Number of Bedrooms umber of Bedrooms��"" 0 Private <br /> ❑ Other Other S LopWl Vd�1nY0om - Well, Spring,Shared <br /> 2/Site Evaluation ❑ Renewal Permit kuthorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ 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 /> Other—Please Specify <br /> I'Jr w Sept i C_ <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.flfl <br /> Eaves <br /> 775 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO box 343 IdANkA , O . q/35b <br /> Applicant's Mailing Address <br /> O4ti1 11-17— 2LI3 t t- <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner [Authorized Representative 2/Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br /> L <br />