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22.— 000 Y5 I— P(` A <br /> Application for Onsite For City Use Only: Date Stamp: <br /> um <br /> - � Wastewater Treatment System City of <br /> Date Received MARION COUNTY PUBLIC WORKS Received by___ R E(�C-I[I f(�L� <br /> BUILDING INSPECTION DIVISION Zoning bY D <br /> 5155 Silverton Rd NE Fee JAN 312022 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt#Activity# MARION COUNTY <br /> www.co.marion.or.us/PW/Buildinglnspection BUILDING INSPECTION <br /> Ki& ..AWL\ S <br /> A.Property Owner Information <br /> )b00J �5OI CIoDf- Jt-� Ys0Y1 Onlq 52_ 5T3- --z3Z <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 /> cm <br /> 509 0---Z-ENcSorl C'k G Vc, 5E '—\--E-C:G VS'0 Ni/ OK— q--13 -z, 1.,,,,,,,444,,,..,,, <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 /> )giSingle Family Residence 3Z Single Family Residence ['Public <br /> 2- 'Z Name <br /> Number of Bedrooms Number of Bedrooms ❑ Private <br /> ❑ Other ❑ Other Well, Spring, Shared <br /> D. Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> .ffConstruction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ 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 /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> kM ( L . \ LL3 503- 910-232`\ <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> Appli is Mailing Address <br /> ' �\kck_ 5 _ '3 1 ) 2 0az . <br /> Signature Date: CCB# (if applicable) <br /> Applicant is thhOwner ❑Authorized Representative ❑Authorization to Apply form Attached <br /> G:\BUILDING INSPECTION\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2018.DOCX Rev 1/15,3/18 <br />