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! - 2 _ 00 3-q 0 EvAL <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ���- Wastewater Treatment System city of \�U M <br /> f0 <br /> ,�^` 1, E �/ E - V E <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by —N] <br /> BUILDING INSPECTION DIVISION Zoning by _ OCT 0 6 2023 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# MARION COUNTY <br /> ww.co.marion.or.us/PWBuildin2Inspection Activity# BUILDING INSPECTION <br /> w <br /> A.Property Owner Information <br /> e� 1 N1\I�,n Coma' ?d k#0k S sr, Poul ok 47i 3 7 SD3 sue'-a)46? <br /> Name Mailing Address City, State,and Zip (Area Code)Phone# <br /> 91070 <br /> 3 R <br /> �/` 1 r B.Legal Property Description D lO A 5 <br /> Legal Description 'V �r- Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> roperty Address 1 " Ciity Q,,,( State Zip Code <br /> Directions to Pro erty: C 7gW t�1 $S• 1 "`'S It Oln 1314`(�C�!r 5 , <br /> T4 1- 719 <br /> r <br /> C.Existing Facility/Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: ? Water Supply: <br /> ['Single Family Residence tl tire.,`., "4 Single Family Residence ['Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Private 3"N1L ',4 <br /> ❑ Other ❑ Other 400 pring, Shared <br /> D.Type of Application . <br /> Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> Construction Permit [I] Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ 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 /> (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 /> Dep ent of Enviro e ality,permission to enter onto the above described property for the sole purpose of this application. <br /> /7 SeanRcorner, so3-�aa6? <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applican ailing Address <br /> 0 /6 -6- -G) 3 <br /> fSi__•-.tor e Date: CCB# (if applicable) <br /> Applicant is th Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SE IC\S- 1 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />