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-55-23- 00I3e17- AL. <br /> Application for Onsite For City Use Only: Date Stamp: <br /> ---%= Wastewater Treatment System City of <br /> MI <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by E f /J <br /> BUILDING INSPECTION DIVISION Zoning by IECE �/ <br /> 5155 Silverton Rd NE Fee .) <br /> Salem OR 97305 FEB 14 2023 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PWBuildingInsuection Activity# MANON COUNTY <br /> j 1 A.Property Owner Information <br /> BUILDING INSPECTION <br /> R)C Gerd 5-heir no, !o-/ 80J 41/Irok-A 1 a It g7Doz So3.7S —34.79 <br /> Name Mailing Address City,State,and'Zip (Area Code)Phone# <br /> 0' I W /lie B.Legal operty Description Z <br /> Legal Description Tax Lot ��� Acreage or Lot s <br /> Size <br /> Subdivision Name Lot Block <br /> /3g7Q 41Arov'G- g70t'2 <br /> Property Address _eI-, , ty i 0 Ste Zip ode <br /> Directions to Property: ta h •7-_-?'lie h R el n eJ r�"ei <br /> RA <br /> C.Existing Facility!Proposed Facility/Water Information <br /> Existing Fatuity: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ' Single Family Residence [Public <br /> '3_ Name <br /> Number of Bedrooms Number of drooms Xprivaie dv�/1 <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> 14 Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> Construction Permit ❑ Permit Reinstatement 0 Replacing a Dwelling <br /> ❑ Repair Permit 0 Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review 0 Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other 0 Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 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 /> / rrvi01cr Sot3 -397- )1(e ) <br /> cant's Na —Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Po . s7/ o /� cre-�L OR 97N' Z_ <br /> +.cant's Mailing • 'dr s <br /> �,� . A i d .,64.1 - OZ '" 3 _ 20Z3 <br /> illSigna e Date: CCB# (if applicable) <br /> e <br /> Applicant is the 0 Owner �Q Authorized Representative Authorization to Apply form Attached <br />