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2 3-- 0-0& 3 3 Au r -1 <br /> ,,,i4g000,,,,` Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System city of <br /> IIIIII <br /> Date Received V E <br /> MARION COUNTY PUBLIC WORKS Received by — <br /> RBUILDING INSPECTION DIVISION Zoning by AUG 1 p 2°N2 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 Receipt# MARIO V COUNTY <br /> (503)588-5147 Fax(503)588-7948 Activity# SUILDING INSPECTION <br /> www.co.marion.or.us/PW/BuildingInsnection <br /> A Pro Owner Information <br /> �}vo1oa,�d--1.uk.Q;:.lkllSaci�,.U,C:.:: :_.. : P� <br /> A-\e4& OttOfS .2-77,'4*N goad Otaca I K. `1102G No3)559-1990 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description39 <br /> . .. .: <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> c- i \mait\vA.1 12ccad be.y vai S 0 91 0 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Isting Facility: Proposed Facility: Water Supply: _ <br /> ingle F ily Residence Singl amily Residence ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms I Private _ <br /> ❑ Other 0 Other Well, .pring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit iA • uthorization Notice for: <br /> ❑ Construction Permit El Permit Reinstatement `�I 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 /> (c \141,1 e VS C5i93) 51c1- 1i 0 D <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> - -1 )- \nAca.}heNw eruct Ciexvuu,S. ibe Gno-u, <br /> Applicant's Mailing Address <br /> 4a, ./Viiiik (0—/1-a <br /> Signature Date: CCB# (if applicable) <br /> Applicant is theg Owner 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 />