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3- 0-033-7 S PieMr <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ~--%-gi Wastewater Treatment System City of r�--- <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by n <br /> BUILDING INSPECTION DIVISION Zoning by c• i S w <br /> 5155 Silverton Rd NE Fee )0• 0 Z <br /> Salem OR 97305 [amc�2 z <br /> (503)588-5147 Fax(503)588-7948 Receipt# G O <br /> www.co.marion.or.us/PWBuildingInsnection Activity# �,' z <br /> ail <br /> ': A,Pro Owner_Informattoti <br /> ' 1LQ.. a�� Q ) Mth iii11 5E TUJI/VLIA0 b1Z17M� nN e rtJ`� 6 ailin Address . Sta e,and Zip Area Code Phon # <br /> g _ <br /> ty> P ( ) <br /> B Legal Pr D cnption <br /> egal Dlitial es np i n 61' <br /> ax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> P VII —P64214/Yeti sr TvAoftw ag_____ 6175qa\ <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 'Single F ily Residence ❑Public <br /> r <br /> Name <br /> Number of Bedrooms Number of Bedrooms ► Private ii/v/( <br /> ❑ Other 0 Other _ Well, Spring,Shared <br /> - D:.=Type of Application <br /> ❑ Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> Er Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer El The Addition of One or More Bedrooms <br /> El Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit El Record Review El Temporary Housing <br /> El Major El 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 /> P <br /> Aa S?i -%q-V-6 <br /> Applic'64 is Name—Please ' t Legibly Applicant's Phone Num�er DEQ Lic.# (if applicable) <br /> ‘51)a. 1WiAlrOn kliI1 'bl 5 lkgw CR- 17Y <br /> Ap lic s 'ing dress <br /> 111 -fa\-a5 <br /> • ature Date: CCB# (if applicable) <br /> Applicant is thOwner El Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />