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A3,o50 Lka IP\ <br /> 1 c--.\\(e2 <br /> �� Application for Onsite <br /> .ne,M� For City Use Only: Date Stamp: <br /> City of <br /> Mi <br /> - - l <br /> Wastewater Treatment System <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildiniInspection Activity# <br /> A•Property Owner Information; , .. <br /> pavia. Shea 2ZS. W /Mo,, 54- Subl„v;kL\ OR- 973W Sb3-93Z-36Sy <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 /> 3 CA S S W;tx a r-a ►At_lwNNs Kd Oaf 6 2 9 7 3 ti k <br /> Property Address City State Zip Code <br /> Directions to Property: /VeX-(- -f-o (Ai a.E-e,4-- W hezv_ jgNr,n.ec,1 incu.5,.Q, <br /> -.:i C.Existing Facility/:Proposed Facility/Water Information <br /> E ' Ling Facility: Proposed Facility: Water Supply: <br /> Ingle Family Residence [7� Single Family Residence ❑Public <br /> `` 2 Name <br /> Number of Bedrooms Number of Bedrooms `(J Private Spr'w ck <br /> O Other 0 Other Well,Spri4g,Shared <br /> D.-Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit DAuthorization Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> ® Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> 5i1 Major © Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> O Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major ❑ Minor ❑ Other 0 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 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 /> rlow\i,nt- Coitgc-I'..tCl-:on 5-03-% 1 1 -2-2@o 39ti 71-1 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> I 1 g()c S St- Sa(e,,.' t(e 1-7 2) 1 ^7 <br /> Applican' ailing Address <br /> 5 t 7/70 23 23GNci.g.. <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner (]Authorized Representative I]Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />