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a3-- a3\ <br /> Application for Onsite For City Use Only: Dare Stamp: <br /> t,,C. Cityof <br /> Wastewater Treatment System <br /> Date Received n ���[lMCMARION COUNTY PUBLIC WORKS Received byD <br /> BUILDING INSPECTION DIVISION Zoning by AUG 2 3 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee ��I�I� i✓a1,3� 9��' <br /> (503)588 5147 Fax(503)588-7948 empty# BUILDING IItiI�p <br /> www.co.merlon.or.us/PWBuildinElnspecfon �Ca�I��9 <br /> A.Property Owner Information <br /> nettle C/ememI Ss'j 1,,joodgrd AitSt 6gIe141 of Cf7317 503'5-957557 <br /> NameMailing Address p City,State,and Zip (Area Code)Phone# <br /> 0 1.w 3b c 0/0° B.Legal.P7 Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 6595-.kooddrJ /'e SI G?1e►vi 6'R 17311 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility.!Proposed Facility I Water Information <br /> Exis9g Facility: Proposed Facility: Water Supply: <br /> Ingle Family Residence ❑ Single Family Residence ❑Public <br /> 3 • Name <br />'. • Number of Bedrooms Number of Bedrooms ghivate <br /> ° ❑ Other 0 Other e Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> ❑ _Construction Permit 0 Permit Reinstatement ❑ Replacing a Dwelling <br /> [ ep ' ermit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> NI Major 0 Minor 0 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> 0 Major 0 Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 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 /> =I;S5 ig; t 5-o � g31-vial 313Z-3 <br /> Applicant's Name—Please Print Legibl Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Ac#;ovi Drti m 3O9a /�cs4m;r Alqr cg s ( 1 r� 17317 <br /> Applicant's ailing Ad J <br /> 487271 Z 50 i 7/ <br /> t pp ) <br /> Date: CCB# if a licab e <br /> Applicant is the 0 Owner ®Authorized Representativethorization to Apply form Attached <br />