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().3-cto-} 6,a <br /> ,, y ` Application for Onsite For Gty Use Only: Date Stamp: <br /> imi. _ <br /> V Wastewater Treatment System City of <br /> Date Received 1 -ECI ,INI <br /> 1MARION COUNTY PUBLIC WORKSReceived byBUII.DING INSPECTION DIVISION Zoning by , q J <br /> 5155 Silverton Rd NE Fee OCT 18 2023 <br /> ��� Salem OR 97305 Receipt# ���9�I� COUNTY <br /> pD3. tJI.J� (So3)588-5147 Fax(503)588-7948 Activity# BUILDING INSPECTION <br /> www.co.marion.or.us/PW/Buildinalnspection <br /> s A.Property Owner;Information <br /> k,,,,,v 1's y 7G '�( r4�v C3,-,k_ eat S C.t�,,.t�..�., ci'7.�fr'l <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> e ' - B.Legal Piopeity Description <br /> OS'tF=o 'goo° 1ao pn 4/3,413 <br /> Legal Description. Tax Lot Acreage or Lot Size <br /> PC cr 1 <br /> Subdivision Name Lot Block <br /> e° R( enne& akrate S <.t /r..ni...- r ti— Cr_ q'T '3 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> 5 C Existing.Facility/:Proposed-Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> NSirigle Family Residence ❑ Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms inPrivate (/Lt'l/5 <br /> ❑ Other . 0 Other Well,Spring,Shared <br /> E D.TYPe:9fApplication <br /> ❑ Site Evaluation ❑ Renewal Permit ithorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement '0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer ❑ The Addition of One or More Bedrooms <br /> f Major: 0 Minor Nt Existinc System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> QMajor ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> Q ( *1 / 0 Other—Please Specify <br /> If the required feeand 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,T 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 /> Oregon Sewer 8,Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 9738.1. <br /> Applicant's Maili Ad <br /> 1'"Z�.•25 201683 <br /> Siattire Date: CCB# (if applicable) <br /> Applicant'is the 0 Owner ''Authorized Representative Authorization to Apply form Attached <br />