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o <br /> cw.td ex4 i, o do -rat- pig On 5t <br /> y ;� Application for Onsite For City Use Only:: Date Stamp:. <br /> �, y City of D E C [I V <br /> � Wastewater Treatment System <br /> ma Date Received <br /> MARION COUNTY PUBLIC WORKS Received by, �` ' <br /> BUILDING INSPECTION DIVISION Zoning by �PR 3 <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)5$8-7948 Receipt# BUILDING INSPECTION <br /> wwwco.marion.or.us/PWBuildinalnspection Activity# <br /> A.Property Owner-Information <br /> Utak �; ju;( t A J,Vti' 't \1 .`5f r � 3 7 -1.f.. U, 05. �i <br /> 1 <br /> Name Mailing Address,] City,State,and Zip (Area Code)Phone<# <br /> B..Legal;property Description <br /> ' ClitID\ .i ire i), ( rrr, <br /> Legal.Descriptien Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 734 i r <br /> Property A dres \ City State Zip Code <br /> M1Dirla,ecti ns to Property:: 0 l� � 4 ` i 1 11 ) <br /> Nr- <br /> C Existing Facility l Proposed:Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> {lS�glFamily ❑ Single Family Residence ❑Public <br /> to a Residence. <br /> Name <br /> Number of Bedrooms Number of Bedrooms ["Private WC I I <br /> ❑. Other 0 Other Well,Spring,Shared <br /> D.Type<ofApplication <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> O Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> Rtepair 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 D Other ❑ Connecting to an Existing:System Never in Use. <br /> (over 5-yrs old) <br /> 0 Other—Please Specify <br /> If the-required fee and attachments are not included.with this application, it will be return edlo 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 th e above described property for the sole purpose of this application. <br /> hr&i tt f n4us N6.1' . 1 q` 3 i 7 35563 <br /> Applic nt's:Name—.Please egiblyf(ct ant's Phone Number DEQ Lic.# (if applicable) <br /> po 6) ) 7Phtkln 1' , a i 10 <br /> liumb_Iicant s. ailing Address <br /> _> • 3 (4 taa? , 419 0 <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner , Authorized'Representative ❑:Authorization to.Apply form Attached <br /> F:IFORMS1 SEPTIC IS-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,:6/22 <br />