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2 —G► oq-( -- P l <br /> z Ot <br /> w►,,, Application for Onsite For City Use Only: Date Stamp: <br /> _ � r Wastewater Treatment System City of <br /> Date Received <br /> 1 MI <br /> MARION COUNTY PUBLIC WORKS Received by [E C [E WEE <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 Fee NOV 2 r 2022 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInspection Activity# MARION COUNTY <br /> BUILL)iNc, INSPECTION <br /> A.Property Owner Information <br /> EV_51AL $ Ac.r4. tAlt-bb al SA Vo,1It,Wt�Sc T'fblCf , oR 9739I 5-a3-8ei -3535 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> ��L� n- c B.Legal Property Description <br /> Legal Description R.�9� Tax Lot 7 . , <br /> Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 8188 VAlII.y W<_.) $c i vYhc,r- ©5Z R73 92 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information: <br /> iPropEa' ting Facility: <br /> osed Facility: Water Supply: <br /> Single Family Residence 0 Single Family Residence OPublic <br /> i f Name <br /> Number of Bedrooms Number of Bedrooms X Private W C...1 1 <br /> 0 Other .S H o?._ N <br /> Other Pin 1 Well, Spring, Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit <br /> El Construction Permit ❑Authorization Notice for: <br /> El Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer <br /> ❑ The Addition of One or More Bedrooms <br /> ❑ Major 0 Minor <br /> ❑ Existing System Evaluation El Personal Hardship <br /> Alt tion Permit ❑ Record Review Temporary Housing <br /> M GI <br /> ❑ Minor ❑ Other <br /> ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> Other—Please Specify <br /> 51+op 13,;,,1d, ►-e loc0.k +Q„k1 Orrni l- vppe• 2 1, ncs arid. re-loco k 'lo bpi-i-v:h <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 /> Kt Al TODZO., nxf‘4.;-I.v" ..503- 9 '3 2-vvey 3 ci 2 3 / <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 8Cq' f L. kLk ck. Sr SAlc✓►. ,. biz G7.317 <br /> Applicant's Mailing Address <br /> 11 /L1 /z1.., I65 Y8 <br /> ature Date: CCB# (if applicable) <br /> Applicant is the El Owner Authorized Representative ygl Authorization to Apply form Attached <br /> F:\FORMS1SEPTICIS-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />