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Application for Onsite <br /> ll,ty e+w, For City Use Only: Date Stamp: <br /> • <br /> --� • Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInsuection Activity# <br /> Property_Qwner Information _. <br /> ruc-t. i��e�- 5951 57 f eov+r.)- Sctew\_ oYeoo, <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B Legal Property Descnpuon <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 5g59 5-1 CA &.i h(\ 012 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Existin Facth /Pro osed Facili <br /> Existing Facility: - Proposed Facility: Water Supply: <br /> jSin le Family Residence El Single Family Residence OPublic <br /> R� tx ✓'rravv\-- `t �rot)vv\- Name <br /> • Number of Bedrooms Number of Bedrooms 12t.Private Li <br /> ❑ Other Other Is 1'O IM la ` .Vi lk Well •S rim S ared " _�_ <br /> �J P g, <br /> Type of Applicatton (().__1A2� / �S : ._ iil � ` �._._. <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> El Construction Permit El Permit Reinstatement El Replacing a Dwelling <br /> El Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor El Existing System Evaluation El Personal Hardship <br /> xi Alteration Permit El Record Review ❑ Temporary Housing <br /> El Major 1Z1. Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> Y <br /> El 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 /> 1 d -S <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> /6173-r koevt. v.oN (.• se- or-9o),v_ 713B3 <br /> Applicant's Mailing Address <br /> ;9-- al16gl S� <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the El Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />