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��..4 Application for Onsite Da <br /> a,, ,„,,,, pp For City Use Only: O <br /> -=_:=� Wastewater Treatment System City of <br /> Date Received <br /> 1VIARION COUNTY PUBLIC WORK Received byf— 0S <br /> BUILDING INSPECTION DIVISION Zoning by 0 P' 2 <br /> 5155 Silverton Rd NE Fee ID 0 o <br /> Salem OR 97305 rn N \n1 <br /> Receipt# u U <br /> (503)588-5147 Fax(503)588-7948 Activity# j1 _._� <br /> www.co.marion.or.us/PW/BuildingInspection . . �.. <br /> A.Property Owner Information 7. <br /> LXWQ ,& " / , 9og s96 .,w,f�5 oe 9955F <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description 0 . 8 5- <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Affacifr5e OO45 <br /> Subdivision Name Lot Block <br /> cue i 9/1. ?# 1f/�`� /yob. A tO 9935-P <br /> Property Address / City State Zip Code <br /> Directions to Property: ''9 & 5,9 o2e� ,-- c /, ,i1/,4 1,i <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 0 Single Family Residence ['Public <br /> Name ./ <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other 0 Other Well, Spring,Shared <br /> D.Type of Application <br /> ❑ Site 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 ❑ 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 /> De artment of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> 4L/e'„"9 r', /to- 5:3 -3 /-25-23 <br /> De <br /> Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> A , /tO y ,: •C y.o�i- Oe 9jj <br /> Ap li t's Mailm A.dress <br /> daWtirr ' <br /> ig <br /> -7. -/4 'M.W <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the Owner ❑Authorized Representative El Authorization to Apply form Attached <br /> F:\FORMS\SEPTI S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />