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.-- n 1 775-TTY\-r--- <br /> ..44,..,..,..., Application for Onsite I-1 <br /> ixo.s...1. <br /> • ---:-:--'-rai'= Wastewater'Treatment System - AUG 2 0 2023 <br /> INIMARION-COUNTY PUBLIC WORKS MARION COUNTY <br /> BUILDING INSPECTION DIVISION BUILDING INSPECTION <br /> 51.55 Silvertan Rd NE <br /> Salem OR 97305 <br /> (503)588,5147 Fax(503)588-7948 <br /> www.co.mnrion.nr.usirtv/Buildineinsnection <br /> .!:Xi. :Pio77.Pef6rO*0-107.076.ii,I.777 777-72-77 7:77Z ''772,%_72,1772,, <br /> 7. -.0eA k_ Cir"ill'ei 1.724.47.3 010.1161-11-(0. 'S <br /> Name Mailing Address <br /> 1:. . - le/ear% . '1 .. ; <br /> 11,14 57, imcilt4 f4 5 --J—e-fcr-err ". 09:— c/7652... <br /> PropertY Address City State Zip Code <br /> i 0q5\o‘\ A 27700 0.6.7 /1:c - <br /> Parr-el# Tax Lot Acreage or Lot Size i <br /> i <br /> rx+ Li zAi‘ay...s IA- ii41cd-71- 6n,(24- <br /> Directions to Property:17-5/ 1P-)44' d+1 _at <br /> 1 LlO•''F:j6tjiiikiafi:t3qLkriirosWIF5aitYjilWlik.tiriiiiiittiroti7Z11T77:„L'M;:-255q77==27-7Z3a:a'z,I. <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 3 OPublie <br /> Name <br /> 1 a <br /> Number of Beximoms Number of Bedrooms. r:antlibn7 9f EinP1°Yeesi Isquilbegr°f 2PIPI°Yee°1 kprivate kfr,Ael f : <br /> Well,Spring;Shared <br /> ................... <br /> O Site Evaluation 0 Renewal Permit 0Authorizatii3n-Notice for: <br /> O Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> iit RIpairPermit O Permit Transfer O.The-Addition of One or More Bedrooms <br /> 0 Major gi Minor a Existing System Evaluation 0 Personal-Had:ship <br /> O Alteration Permit la Record Review 0 Temporal),Housing <br /> 0 Major Of Minor 0 Other 0 Connecting to an Existing-System Never in Use <br /> (over 5-yes old) <br /> 0 Oilier—PleastSpecify <br /> If the required fecand anachmemsare not Included with this application,it will be returned to you as.incomplete. <br /> Post the orange card at the entrance to the proudly, Flag the test holes. <br /> By mysignature;I certify that the information l'haye 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 thosnle purpose ofthis application. <br /> Pit iC.44\ Adze" .5z15-710 -2-5457 • 'Ncii4f3 <br /> Applicant's Name:—Please Print Legibly Applicant's Phone Number DEQ Lic.WV applicable) <br /> i 1 <br /> -9343 '...tIN k—A:vc_ Cl'ele-11\- 4 i ltI.Of--T q752-7 VIA iacka heoctre04-6Acz .vid- <br /> Applicanes,Mailin Address Email: <br /> 45 11:2".(7-5 `20l06S <br /> t ure Date: CCB# (if applicable) <br /> Applicant is the ['Owner NAuthorizedRepresentative(form attached). <br /> GAPILEDING INSPECTIONIFORMSISEPTIMS;01°NUM APPL JULY 2023 REY 623.DOCC Rev 1/15,3118.sfra,612.3 <br /> ----,., <br />