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t 3- 6but �5-1 <br /> Application For City'ilse Only: <br /> for Onsite. _ Date stamp: <br /> G Wastewater Treatment System citrof D M <br /> Date Received. <br /> Received by. J MARIOI+i:COUNTY PUBLIC WORKS _ --I <br /> BUILDING INSPECTION DIVISION Zoning,by MAY 17 2023 <br /> 5155:Silverton Rd-NE Fee <br /> Salem OR97305 ��I®l COUNTY <br /> (503)°588-5142 Fax(503)5884948 Receipt#_. .... _. <br /> - • . BU LDING INSPECTION <br /> www.co.Marion.or:us/PW/BuiidineInsaection, Activity# <br /> A.PropettyOwner Information <br /> Hwy 99 LLC PO Box 1130 Wilsonville,OR 97070 <br /> Name Mailing Address City,State,.and Zip (Area Code)Phone# <br /> ;B.'.Legal Property Description:. • <br /> 051W04010001 30.76 <br /> Legal:Description Tax Lot Acreage or'Lot Size <br /> Subdivision Name Lot Block. <br /> 12120 Ingalls L n NE Woodburn OR 97071. <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 <br /> ® Private Well <br /> ❑ Other ❑, Other Well,Spring,Shared <br /> D Type of Application <br /> Site.Evaluation '❑,. ❑ ReaewahPermrt ❑Authorizahon:Noticefgr: ' <br /> 121 ConstructionPermit ❑ Permit Reinstatement El Replacing a Dwelling <br /> ❑ Pertnit p El Permit Transfer ❑ The.Addition of One or More Bedrooms <br /> IZe air <br /> ❑ Major ' <br /> E IVmor ❑ Existing System Evaluation 0 Personal Hardship <br /> Permit. Record Review❑ Alteration ❑ ". ,, ,, ❑ 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:reguired 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 mysignature,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 /> A-:Affordable Septic Service 503-682=1929 37918 <br /> Applicant's 1Vaine ;Please.Print Legibly Applicant's,Phone Number DEQ Lic.# (if applicable) <br /> PO Box 818 Canby, OR 97013 <br /> t- a 3 158246, <br /> ignature Date: CCB# (if applicable) <br /> Applicant is the❑Owner I]Authorized Representative ❑Authorization to Apply form Attached <br />