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a3 bq\- <br /> Application for Onsite For City Use Only: Date Stamp: <br /> .�-�' Wastewater Treatment System City of <br /> Date Received Received b [fEDEIVII-En <br /> MARION COUNTY PUBLIC WORKS y <br /> BUILDING INSPECTION DIVISION Zoning by FEB 012 E3 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION C....1 J "STY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING INSP,X.)i•ION <br /> www.co.marion.or.us/PWBuildinglnspection Activity# <br /> A.Property Owner Information <br /> David Trachy 4394 71st Ave SE _ Salem, OR 97317 714-686-4927 <br /> Name Mailing Address City,State,and Zip _ (Area Code)Phone# <br /> B.Legal Property Description _ - ___ _ - - - - <br /> '4394 71 ST AVE SE SALEM 529685 3.1 Acres <br /> Legal Description Tax Lot Acreage or Lot Size <br /> 1300 082W10D <br /> Subdivision Name Lot Block <br /> 4394 71st Ave SE Salem OR 97317 <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 /> giSingle Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ® Private Well <br /> 0 Other ❑ Other Shop with Bathroom Well,Spring,Shared <br /> D.Type of Application <br /> - <br /> . <br /> 0 Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> El Major El Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ] Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ® Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> Add Septic Tank to (over 5-yrs old) <br /> Existing System ❑ 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 /> David Trachy 714-686-4927 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 4394 71st Ave SE Salem, OR 97317 <br /> Applicant's Mailing Address <br /> I Signature Date: CCB# (if applicable) <br /> Applicant is the®Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />