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1 d3-4tb875,(14) <br /> + , , Application for Onsite For City Use Ouly: o : <br /> Wastewater Treatment System City of <br /> IIIMDate Received 11--- CiE `\/JIE ...) <br /> MARION COUNTY PUBLIC WORKS ivedbyvBUILDING INSPECTION DIVISION -15155 Silverton Rd NE F � OCT 18 2023 <br /> Salem OR97305 ���0N COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> V*IAw.ccr.marion.or.us/P1h`/Buildinelnspection Activity# SAILDING INSPECT ION <br /> j f A.Property Owner Information <br /> K:c.r t tr h cv r y Gc t 4 6.cr rz..,< SE S.1 e is vZ .-�z3g-r <br /> Name / Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> OS'I& 1 iscc',n is c) Inn Lf3.-IS <br /> Legal Description Tax Lot Acreage or Lot Size <br /> p ci cJ 1 ±± s <br /> Subdivision Name Lot Block <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 /> OSingle Family Residence 1E1 Single Family Residence ❑Public <br /> 14 Go( Name <br /> Number of Bedrooms Number of Bedrooms NI Private Wet( "(Jra pe ua( <br /> ❑ Ott ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> • Site Evaluation 0 Renewal Permit ❑Author ization Notice for: <br /> ❑ Construction Permit 0 P• ermit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit El Permit Transfer El The Addition of One or More Bedrooms <br /> 0 Major ❑ Minor El Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 R• ecord Review 0 Temporary Housing <br /> El Major El Minor El Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 7 cc.;., roue-'(` 6.44k.` w Q S . ire Alf 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 /> Oregon Sewer&Drain LLC 503-874-9414 38968 <br /> Applicant's Name—Please Print l eg.bly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton,OR 97381 <br /> Applicant's Mail' d <br /> -.%Za 3 201683 <br />, 2 tore Date: CCB# (if applicable) <br /> Applicant is the 0 Owner VrAuthorized Representative VAuthorization to Apply form Attached <br />