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23 - 005-6(SZ Pritirr <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ;,,,.'' Wastewater Treatment System City of pECMVE0 <br /> MN Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by L !Ls F 12 6 2073 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARIC N COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSPECTION <br /> w .co.marion.or.us/PW/Buildinslnsnection Activity# <br /> ww <br /> A PropertyOwner Information <br /> (4r/ v, z" /'` e.f se j,�o m d 4 riA7 C a . -- ,Sd s' - <br /> t"a.4/5-i� da,.,, 3 0 b rf c• . Scu�rwt G2 ,...7- <br /> 7�r� 2 / i -7 <br /> Name Mailing Address City,State,and'Zip (Area Code)Phone# <br /> B Legal Property__Description <br /> d 4 2 L / 7 i 00O g 6 2 a-cca <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Syr ., Park 7 <br /> Subdivision -Name (l+ �� jf Lot Block <br /> 2. 33 c /7 ✓ a.0lTL, et.rq{V WAY L,eGA. S V'' <br /> ` 97 3S"Y- <br /> Property Address City State Zip Code <br /> Directions to Property: Nu) y Z z a"s 4' f o Sa A 14! ci A A- O/c- 4y <br /> . 1 <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence VSingle Family Residence ['Public <br /> Lii 't'k✓ Q C Name <br /> Number of Bedrooms Number of Bedrooms 'Private C<1 e (1 <br /> ❑ Other 0 Other Well,Spring, Shared <br /> L 4 — 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 /> 2 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 /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applicant's Mailing Address <br /> e J. dc:„Ca 6 /26/a3 <br /> Signature U Date: CCB# (if applicable) <br /> Applicant is the CgfOwner ❑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 />