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-01V4/4/1.7- - <br /> Application for Onsite For City Use Only: 0)ate Stamp:�. <br /> ���= Wastewater Treatment System City of 2.C = 0 <br /> Date Received ��., <br /> •z„Mil MARION COUNTY PUBLIC WORKS Received by 0 M <br /> BUILDING INSPECTION DIVISION Zoning by 130 o <br /> 5155 Silverton Rd NE Fee Tl C N <br /> Salem OR 97305 �j 3 !J u <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# ' <br /> 11 __ E. t.E_x 2.._i,. A Property Owner Tnfarmatton 3 <br /> 3 <br /> tf Oak(C1 Y e O 0vn I Olt V* Cr- N- '-tex.) oK °1i30-5 503.93 i - 0 1 <br /> Name Mailing Address J City, State,and Zip (Area Code)Phone# <br /> __...._B Legal Property Descriptiot .. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> A4—g&9 W 9 Pla.ca. PE 5alevv oiK 91-3D l <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C Exstin Facile /Pro osed Facil /Water Tnformatian'' <br /> Existing Facility: . Proposed Facility: • Water Supply: <br /> ['Single Family Residence [r Single Family Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> ❑ Other 0 Other Well, Spring, Shared <br /> '_..... .• D Tofype Apphcation. , ' l <br /> ❑"Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> [ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review El Temporary Housing <br /> ❑ Major ❑ Minor El Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <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 /> LOture l P -ersoIn 503- 31 - oSB <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ID -2 Est Lv cL C -. 3. Kt ze,,r, C YZ QUI-30 l , <br /> p icant's Mailing Address <br /> 1 )9,2a2A <br /> ature Date: CCB# (if applicable) <br /> Applicant is the 1'1 •wner ❑Authorized Representative El Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />