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r <br /> 2 s- 0_0 cr f 5---e vbet-1, <br /> Application for Onsite For City Use Only: Date Stamp u <br /> _ -- Wastewater Treatment System City of c <br /> Date Received • D �ul <br /> r it �� <br /> MARION COUNTY PUBLIC WORKS Received by ▪ O <br /> BUILDING INSPECTION DIVISION Zoning by _, F--► <br /> 5155 Silverton Rd NE Fee 3 np cn FH <br /> Salem OR 97305 r rl c <br /> (503)588-5147 Fax(503)588-7948 Receipt# t) z 1-..2 <br /> www.co.marion.or.us/PW/Buildinenspection Activity# _ C5 -< �' <br /> z <br /> // A Property Owner Information c-----J ... <br /> ' a L{al7ree✓ I$cb34 Arbor Grovr,R), AiF 1i o vlit A. ?707 I ,563—7cz.-73 7 2-- <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 / l Block <br /> a'i4cr (rwov- <br /> %%3`� � ' loo" 4 6 <br /> /i- ' 0 01 Ldvd, 9'7o7 / <br /> � <br /> Property Address, City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ►i Single Family Residence ❑Public <br /> • Name __ <br /> Number of Bedrooms Numbof Bedrooms Private 11 <br /> O Other 0 Other Wer Spring, Shared <br /> D.Type of Application <br /> '1 Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration 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 /> 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 /> rih Y4 /1.(abeev So3 -75z-7 3 7 Z <br /> Applict's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 21,1 l?0V �otPC /ed IVE l�00I 1/4-0l 04 - f707/ <br /> Applicants Mailing Address <br /> -(-Ki, - 6 -//— 1-, <br /> afore Date: CCB# (if applicable) <br /> Applicant is the❑ Owner ❑Authorized Representative KAuthorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />