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NN.,...____ , , - 59, <br /> Application for Onsite <br /> pp For City Use Only: Date Stamp: <br /> _�� Wastewater Treatment.System City of ff `` (I Date Received V I�' If IJ vf <br />, <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by 1aU 18 2022 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MA. ION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> www.co.marion.or.us/PWBuildinUInspection Activity# <br /> :. : ; `A Property Owr<erinformation ', . . �.. _..._.. , .- .._ ,- <br /> 2'do4l1to. - betoo4 foe- Pn I3oce 3 97 .JILKltit_ t CT) 973.5-v sr,?gsy 3s'-!a <br /> Name Mailing Address City, State, and Zip () rea Code)Phone# <br /> B..Legal Property Descnphori- , ,_ . <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 15`SG H t.c,\( z z 5c= ,z'Act-Ktvt. C It 9'73 es-E' <br /> Property Address City State Zip Code <br /> Directions to Property: 0 f c }-I uo 1 y Z Ok -¢p `3101v Dt-L'r]Z,C! . 13o cr+y i c 7`lre <br /> Cull-Aar IaefV rc Coof racy vA•tc r'lUGJ <br /> .. ,_.. C Existing 'acility_I Proposed.FacilityJ Water,Information' . ,,' ~ .,._, .. <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other Other r1`P 4 .lids-F:Ort Well, Spring,Shared <br /> .. .D Type off.Application. <br /> ErSite Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major E 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 /> z T""is, )4 btr_gii pd...r , (over 5-yrs old) <br /> ❑ Other—Pl ase Specify ,, <br /> /4'Pe e- `S1W`P. tii« - '-'4`'en-.N L p'I-t ' z. " - )500`ItakOl•tftt r4i s24` "1.ky,r' ) 4;3 <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 o.f the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> retd.lia- r$0`t co 3 9e, 5(95i <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> pe 13av 377 ..z-dACitl o R. 97 3s© <br /> Applicant's Mailing Address <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑ Owner ❑Authorized Representative E Authorization to Apply form Attached <br />