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bb l Le <br /> Application for Onste For CityTECEM-F <br /> �4y w� pp Use Only: <br /> Wastewater Treatment System ci of <br /> Date Received <br /> Mil, �J <br /> MARION COUNTY PUBLIC WORKS Received AUG 18 2022 <br /> BUILDING INSPECTION DIVISION Zoning by ���i�� COUNTY 5155 Silverton.Rd`NE. <br /> Salem OR 97305 Fee BUILDING INSPECTION <br /> (503)588,5147 Fax(503)588-7948 Receipt# <br /> www.co:marion.or.us/PW/Build►nginsoection Activity# <br /> A.Property Owner Information <br /> 141.t.kb-e.1 lr Fetmelc,. L t.tIer 73 3' Slxe1 414 Se 5ekke,ut. O 9?-(' 7 S03-937 - 7115- <br /> Name Mailing Address City,State,and.Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description: Tax Lot. Acreage or Lot.Size. <br /> Subdivision Name Lot Block <br /> 1 a5 s . FCA.1-4 .14 IZ De... -.(-c i 1- ev ql3 'f <br /> Property Address City State zip.Cock <br /> Directions to Property: <br /> C.;Existing Facility/Proposed Facility 1 Water Information <br /> Existing;Facility: Proposed Facility: Water Supply: <br /> ❑Single:Family'Residence zi Single FainilyResideice ['Public <br /> 3 Name. <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other ❑ Other Well,Spring;Shared <br /> D.Type of Application. <br /> 0, Site Evaluation ❑ Renewal Permit E Authorization Notice.for: <br /> ❑ Construction Permit ❑ Permit Reinstatement Et Replacing a Dwelling <br /> Repair.Permit ❑ Permit Transfer ❑ The Addition of'One or More Bedrooms. <br /> (l Major ❑, Minor ❑, Existing System Evaluation El Personal Hardship <br /> AlterationEl :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 /> lithe i equir.•ed 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 inforinationI have furnished is correct,and herebygrant Marion County;authorized agent of the <br /> Department ofEnvironn ental.Q'uality,permission;to enter onto the above described;property for the sole purpose.of this application. <br /> ):evv 1 y ef 5O3 c 4/9 /E)?4 8 '5 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number. DEQ Lie.# (if applicable) <br /> 0 Nam . ? t ( Sfi kefFer a 97367 <br /> _____±. ,. <br /> Applicant's Mailing.Address <br /> ar g/(s/ ? /6 57&& <br /> Signature j Date: CCB# (if applicable) <br /> Applicant is the•El Owner ❑.Authorized.Representative ❑Authorization to Apply form.Attached <br />