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1 <br /> 023 -tsbiL 5LQ <br /> Application for Onsite For City Use Only: r.pan P. <br /> �� D Wastewater Treatment System city of L <br /> Date Received �� i✓ <br /> E i <br /> MARION COUNTY PUBLIC WORKS Received by D <br /> — <br /> aim <br /> 1. <br /> BUILDING INSPECTION DIVISION Zoning by MAY 19 2023 -_ <br /> 5155 Silverton Rd NE Fee pi(O L �t`!j i <br /> 503 588 5147 Salem OR <br /> (503)588-7948 Receipt# Ut' DING f�'JSPEo <br /> (503) Activity# T�(aN <br /> www.co.marion.or.us/PW/BuildinaInsiaection <br /> A.Property Owner Information <br /> civis kStarai jot- 449D $a-}eS 9.ict S Sattm,og.4-t3 oto 566- 131• ( 76f0 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> g 31 i I A q B.Legal Property Description a • 3 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> SUnn 51 Ott F r4 tarm5 fl .2-9 <br /> Subdivision Name Lot Block <br /> -qaa *itS VA S . 5atO'1 .- a 730(n <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility l Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms $ Private shared e" t1 <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 /> O Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major 1211 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yes old) <br /> Ili- t C The. LS; dvp bCx V. X 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 /> , B '- C fr1C u1-q —0gS1 3S13--i-- <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> ?o f.a 4 4- 4- 4llo t . q 13 Z1 <br /> pp is Mailinit A s <br /> ` � <br /> �, : ; rg' 23 15 G31 <br /> Si ure Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative 0 Authorization to Apply form Attached <br />