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2 33z--( 3 LuvirL <br /> Application for Onsite DateStam <br /> For CityUse Only: p: <br /> Wastewater Treatment System City of --13)Date Received E C [E 1 \J E D <br /> MARION COUNTY PUBLIC WORKS Received by -� <br /> BUILDING INSPECTION DIVISION Zoning by - 6U_ 25 2023 --1 <br /> 5155 Silverton Rd NE Fee • <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> www.co.marion.or.us/PW/BuildingInspection Activity# BUILDING INSPECTION <br /> A Property Owner Information <br /> JUC14l C. WG('CU lo'Oo ajYUShCcee,1-ocNG- Gj,tueftc7rl102, ct) 81 l,3\" ca,-4 c5ti <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> 13.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> (vCloM•C:lgh ueeti. O,r i'i co;tue(ivfn OR- al301 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence 0 Single Family Residence DPublic <br /> Name <br /> Number of Bedrooms Number of Bedrooms fp Privatell <br /> ❑ Other [VD Other c ylov OC1 rwoo cn Well,Spring, Shared <br /> D.Type of Application <br /> Site Evaluation .•• El Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> El Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> IliAl Alteration Permit El Record Review El Temporary Housing <br /> VAS Major El Minor ❑ Other El Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> El 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 /> Sklar\'rutr\CO (.GjU'3)lc1`b - ‘ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> loS1o1 \?J('Y ('feet', Of Ne. , ._j0it�! i,-UY,0 09- c+:n3Cb` <br /> Applicant's Mailing Address <br /> bliau1acsa: <br /> S gnature ''41 <br /> Date: CCB# (if applicable) <br /> Applicant is the Owner El 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 /> f c0c eA0v -Li ®O 0 c EOOv_ .GO <br />