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P tQW'T-0( <br /> 2 3 oo 5oz ll-- M-u t- <br /> , ,,y„, Application for Onsite For City Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by EC <br /> E 17 V <br /> BUILDING INSPECTION DIVISION Zoning by D <br /> 5155 Overton Rd NE Fee JUN 13 2023 <br /> Salem OR 97305 <br /> 503 588-5147 Fax(503)588-7948 Receipt# �/IARI®� <br /> ( ) CO UNTY <br /> www.co.marion.or.us/PW/Buildin2Inspection Activity# BUILDING INSPECTION <br /> A.Property Owner Information <br /> L * ()MI( KvEitZl 6878 IV'e$3 -7r Sr Se, fL 'l1a- 9 '.- <br /> 73i 7 043 $sA.1.! <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> d 7 P-W 3 4 e/4 60 55"©d B.Legal Property Description ,�� t'�S <br /> call Co05 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> (p£78 ZuWE: r sf_. , -E4"t — 973i7 <br /> Property Address City State Zip Code \ <br /> Directions to Property: hr or S i19-7t, S i, RA f�i'r . (Sixm) oiv •7D pi , -i,j 1 gi(fH r(L c iz) <br /> O ArTb gaiwEir 5tf; i 54-k HOUSE oil) F'i <br /> C.'Existing Facility/Proposed Facility/Water.Information.,; <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence a Single Family Residence ❑Public <br /> 3 /�/ Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> 0 Other ❑ Other Well, Spring,Shared <br /> D.Type of.Application ,,, ,t. <br /> ❑ Site Evaluation ❑ Renewal Permit giAuthorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> - Re'air Permit ❑ Permit Transfer Z The Addition of One or More Bedrooms <br /> • .J Major ❑ Minor 0 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 /> 7?i 2 KLAFA)ZI 5o3--383-8 8a'- Hvt *i.:vEl- <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> CO 7 8 2?v4Nf-'tr 5't- 5 ) 9 73 i <br /> Applicant's Mai i g Address a <br /> /26,p_s <br /> S nature Date: CCB# (if applicable) <br /> Applicant is the .Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />