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i <br /> 2g-00g0614 EVAL <br /> .,,, ,,,,,. Application for Onsite For City Use Only: Date Stamp: <br /> _ ;,;,�, Wastewater Treatment System City of /\1//��J�7 _ \\\///J <br /> ED <br /> MN Date Received <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by _ 11 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 /> www.co.marion.or.us/PWBuildingInspection Activity# BUILDING INSPECTION <br /> ea4ErA Property!Owner Information <br /> NO 1 N1\Ic Coonot j() 0x S. GT. Poeu i oR 4713 7_ S ScF1-a)6? <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> r'' B Legal Property Descnption <br /> 91003Roj\siA,.t ' .N _ Arices <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> •roperty Address ii741C_ity State Zip Code <br /> Directions to Pro erty: $ • PtgA , I�e.�`t' oln Q I c c -ei 5 O <br /> 'f'K '� O r�Tt9 � <br /> C Existing Facility/Proposed Facility/WaterInformation <br /> Existing Facility: Proposed Facility: Z Water Supply: <br /> ['Single Family Residence OU $ Single Family Residence ❑Public <br /> 3 Name` <br /> Number of Bedrooms Number of Bedrooms Private 5\CN . ',♦ <br /> ❑ Other ❑ Other kitiV Spring, Shared <br /> D.Type of Application <br /> Site Evaluation CI Renewal Permit ['Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer Li The Addition of One or More Bedrooms <br /> ❑ Major Cl 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 /> R58ah R Connor s-r.) -1/458 aa69 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Applican : aiing Address <br /> r � <br /> /6 a 3 <br /> ' i :tore Date: CCB# (if applicable) <br /> Applicant is th; I Owner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SE• IC\S4 1 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />