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On siteDate Stamp: <br /> Application for 0 s nl : p <br /> For City UseOnly: <br /> Wastewater Treatment System City of1111111 <br /> D �❑C �� <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by MAR 07 <br /> BUILDING INSPECTION DIVISION Zoning by 2023 LJJ <br /> 5155 Silverton Rd NE Fee MARION COUNTY <br /> Salem OR97305 Receipt# BUILDING INSPECTION <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PWBuildineInsuection Activity# <br /> A.Property Owner Information <br /> udC 11;a� 3011 MAIne,loc4 S€ Se.,.Ie ' 02 91317 co3 4130 26'( 2 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> 301\ C-1 SE S.4eN, a R 083w'IA- Rao 1 edo I . 11 <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 10 idNA, ES-,}es 1.. <br /> Subdivision Name Lot Block <br /> 3D Mti��,l�� c+ s E_ OR <br /> Property Address City State Zip Code <br /> Directions to Property: f- . 1^ E) 1 Nz11� � f AiM 4/r% ktO'WCS4"% M-A 1..% jv Cl S <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> L93tigle Family Residence 8-Single Family Residence ['Public <br /> 3 0 Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other [}'Other .Sk o P Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> eration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major a4'Minor ❑ 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 /> Jam, de F11'd So3-cj o - 2/912 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3° 11 M ki•I D C f s F S ( efi2 <br /> Applic is Mailing dress <br /> Signa Date: CCB# (if applicable) <br /> Applicant is the 0 Owner 0 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 />