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aa-nIocit,n <br /> v-�� <br /> Application for Onsite For City Use Only: Date Stamp: <br /> �_"_= Wastewater Treatment System City of <br /> 1----: ECIF:OVEDI <br /> INN Date Received <br /> MARION COUNTY PUBLIC WORKS Received byif q Nov <br /> 3 BUILDING INSPECTION DIVISION Zoning by • 0 ZQ�Z <br /> 5155 Silverton Rd NE Fee MARION G ICI COUNTY <br /> Salem OR 97305 i <br /> (503)588-5147 Fax(503)588-7948 Receipt# B L I LD I N G INSPECTION <br /> ww.co.marion.or.us/PWBuildinsInsnection Activity# <br /> w <br /> IAA 2 WESTBROOK CORPORATE CTR 10TH FL,WESTCHESTER IL 60154 224-500-8633 <br /> Name Mailing Address City,State;and Zip (Area Code)Phone# <br /> ter. .- -. _+---� �. t. nn.: ,x?,. .�,= _ - g. _ ,.��—_ rs•�,: <br /> _=,.�_._. �. rya— �.— .. <br /> 051W18D000400 8.82 acres r <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> • <br /> 605 S Pacific Woodburn OR 97071 <br /> Property Address City State Zip Code <br /> Directions to Pro a South of E Cleveland Street <br /> P rty: <br /> `r y—�` `l- - ttr i � �" Math00 fl -7 tB 0 tl a-'.r __ <br /> Existing Facility: Proposed Facility: Water Supply: • <br /> 0 Single Family Residence 0 Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ® Private Well(Well Log: MARI 69629) <br /> ❑ Other ® Other Modular office building ID Well,Spring, Shared <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> XConstruction Permit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review El Temporary Housing <br /> ❑ Major ❑ Minor ❑ 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# if applicable) <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner 0 Authorized Representative ❑Authorization to Apply form Attached <br /> F:IFORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6t22 <br />