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, -do Yry-- iieiti4r <br /> �, Application for Onsitej For City Use Only: 4.J nV <br /> Wastewater Treatment System city of a <br /> . _ <br /> Date Received MAY 1, 9 2022 <br /> NM MARION COUNTY PUBLIC WORKS Received by ��I <br /> COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by � <br /> 5155 Silverton Rd NE BUILDING INSPECTION <br /> Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildinglnsPection Activity# <br /> ., . j,, ... . _,0.., :A_Pilo arty QwnetIn€Dana a ti . _.._ �... _ r... a ,.. . . . <br /> .e LA0 k� t.l.c P.6 'ox 78SZ l tsov.,1i(Q Or 770Z. S)? 779 66? <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ' tS Legal Fropetiy 7iscri i.ATI r <br /> Legal Description TeX Lot Acreage or Lot Size <br /> i <br /> Subdivision Name Lot Block <br /> 2,Z-6C( 51-ei+.c3er re) SC U2 `e.rSoK 0r 7gS—Z. <br /> Property Address City . State Zip Code <br /> Directions to Property: <br /> ?.:C±O ist i,P.: drty 1,44:0 dt actlitp Water Informs 90. .. .1 Existing Facility: Proposed.Facility: Water Supply: <br /> 1 <br /> ['Single Family Residence M..Single Family Residence ❑Public <br /> r/ Name <br /> Number of Bedrooms Number of Bedrooms IDPrivate <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> sx f J^ <br /> ' x g. F " .. Type ofµAppt�catcon ., i ., �x .Ei. �. .£, k^..,<F..Y .5, r, <br /> El Site Evaluation ❑ Renewal Permit I DAnthorization Notice for: <br /> IRr Construction Permit ❑ Permit Reinstatements ❑ 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 1 ❑ Temporary Housing <br /> ❑ Major ❑ Minor El 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 /> Vr e-vv Cc.tyei co3; 9 " (86, 3 853 W <br /> Applicant's Name—PleasePrint Legibly Applicant's Pone Number DEQ Lic.# (if applicable) <br /> 90 26x zi(s© iciAtrei, (5` 97?O 2 <br /> Applic 's Mailing Address <br /> 5` l0 2 <br /> Signature Date: CCB# (if applicable) <br /> t <br /> f • <br /> Applicant is the❑Owner ❑Authorizid"Representative El Authorization to Apply form Attached <br />