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02 --(DbC)11 CA <br /> Application for Onsite For City Use Only: Date&mar <br /> Wastewater Treatment System City of <br /> am <br /> Date Received � [E <br /> MARION COUNTY PUBLIC WORKS Received by EE TT <br /> v <br /> li <br /> BUILDING INSPECTION DIVISION Zoning by LNOV 3 0 2023 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MAR i O IN COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> Activity# BUILD NG INSPECTION <br /> www.co.marion.nr„usiM/Buildintinspectinn <br /> A.Property Owner Information <br /> Jc,66 ,.. 0,iteAA 373g e,,,,.-,ce,t e_ c <,.ta.,,. ,en2 C.Z() (z <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 3ei` 9 tZ(,x,rcC, L r't S S e.Lei--t. C7 i` c1r-3 crL_ <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 /> ®Single Family Residence ❑ Single Family Residence ❑Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms B Private Well <br /> O Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> Alteration PermitRecord Review 0 Temporary Housing <br /> EI Q 0 <br /> Major Ej Minor 0 Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> .//�y� G-4- � c�3L. ❑ Other—Plle�assye.�S.�p/ecifiy-- wvf qyj <br /> ' � �� L� PshYL /1L./R✓Le,.- t I X-Italei Lae_ pcize4/1v 6 k.etk <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 Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO Box 1282 Silverton, OR 97381 <br /> Applicant's •' g s <br /> 11- 'o_-`� 201683 <br /> nature Date: CCB# (if applicable) <br /> Applicant is the 0 Owner Authorized Representative SfAuthorization to Apply form Attached <br />