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2 I PMT <br /> 23 2 <br /> Application for Onsite For City Use Only: Date Stamp: <br /> City of EC EEIVE --. <br /> %%;1•� Wastewater Treatment System v ` <br /> mI Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by SEP 2 8 2023 --J <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/BuildingInspection Activity# BUILDING INSPECTION <br /> • <br /> A.Property Owner Information <br /> 9 6 b - 3mcj 180S Deft? Lni fE T .ynel -aiP 4-715.( <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> t 05 Dvi, (,v SE rt.-, be_ 4-nq <br /> Property Address City State Zip Code <br /> Directions to Property: r li,- (3P -. ak,e_ )1o4IL 4-Nrei )e - r)A (y tc...►-e ear. <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ['Single Family Residence Single Family Residence ['Public <br /> 4 Name <br /> Number of Bedrooms Number of Bedrooms [-Private _ �..i I <br /> ❑ Other LI Other el Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> lig 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> a cm,e( 64—ekvc,j-415 -Ct?3- 9113-21113 S6I ,8 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Pd Oa s011 T(trner UP e'77ciz__ <br /> Applicant's Mailing Address <br /> (e,-I4 .d 9 /a Biz 9 Weiss) <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 Authorized Representative 0 Authorization to Apply form Attached <br />