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03- .S.u.-1 LQ� <br /> .,,, Application for Onsite For City Use Only: Date Stamp: <br /> 'Wastewater Treatment System City of D Date Received -E C E g L/ -� <br /> IllilMARION COUNTY PUBLIC WORKS Received by J <br /> BUILDING INSPECTION DIVISION Zoning by MAY 26 2023 <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee MARION COUNTY <br /> t#Receipt(503)588-5147 Fax(503)588-7948 Activity# BUfLD!NIO INSPECTION <br /> www.co.marion.or.us/PWBuildin2Inspection <br /> A.Property Owner Information <br /> R � rohnr�t.�ff 10177 6t-c ion R4 4v?1iviIj , oi? 77325" So3- 507-62$2, <br /> Name P Mailing AddresA City,State,and Zip (Area Code)Phone# <br /> 0 11W 18 D o o d 74° B.Legal Property Q Description70 78 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> I0I-77 St'6)1t0311 PA eJF PitriN,Svil�� op 97325 <br /> Property Addreda C ty State Zi Code <br /> Directions to Property: I0177 51-ef h R 0. /�V�lswilf p <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Eaistjhtg Facility: Proposed Facility: Water Supply: <br /> PP1Y: <br /> Single Family Residence ❑ Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms vate <br /> 0 Other • 0 Other CP.pring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ ons tion Permit El Permit Reinstatement El Replacing a Dwelling <br /> 1[ Rep Permit 0 Permit Transfer El The Addition of One or More Bedrooms <br /> Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor ❑ Other 0 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 /> Te55 l i. ehitilQ 503-732--21/o/ 3‘323 <br /> Applicant's Name—Please Print Legigy Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3690 HaAr ra— L3 € 5E 5fi 1. 6/? 17 l7 <br /> Applicant's ailing Address J <br /> 0 5// 7/23 .c0/n . <br /> S. Date: CCB# (if applicable) <br /> Applicant is the❑Owner Authorized Representative Authorization to Apply form Attached <br />