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f , <br /> 0/4-6'1f r- ,*4- <br /> . � a VED <br /> .,,, :,,,„, . Application for Onsite For City Use Only: ` ` Date Stamp: <br /> Wastewater Treatment System City of • JUN 1 2024 <br /> Date Received <br /> 111111/ MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Silverton Rd NE. Fee • <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> ww .co.marion.or.us/PWBuildingInsnection Activity# <br /> w <br /> RiginitiliiiiiiiiingagniiiiintitiliiiiiiiiiiiiMIE <br /> A.Mat t wn r l_nfQrm4p g-EEF - - --- u : : --- <br /> h1LPaJI/ _: <br /> 7q�• � �y ��S £5) — 7Oz( �� !0-�3 <br /> Name Mai•ling Address city, State,and Zip (Area Code phone# <br /> _._::. .------ MB LegtOrope ly Dsscriptip------=------- <br /> L scription Tax Lot Acreage or Lot Size <br /> Sul isien- Name L-et_, Block <br /> 7 c.1 5/a:(11, l G �� c__ q) )2 <br /> Property Address �} ,,L / .Ci _C /�' State Zip Code <br /> Directions to Property: [%1 5/ ihi'e.i I-,— 9&r[1 J v 1� g7(1 Z4 <br /> ldE k tin Fac Pzo osa fMr4 C f4zm tzota d <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Single Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑ -Other ❑ Other Well, pring,Shared <br /> r <br /> __..ifi 3 .:3c. _ ..:....:.. £7 Type. f�Appl atlol:'l. ........ _.__._.._ .... ._..._ _-_ .::F...... <br /> mmummagmitioillom <br /> U..Site Evaluation 0 Renewal Permit ❑Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ .Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms - <br /> • ❑ Major El Minor ! Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit E. Record Review' ❑ Temporary Housing <br /> .- ❑ Major ❑ Minor ❑ Other El 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, itwill 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 /> ' .y [ e 3,71©,�3� <br /> App cantis Name—Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 166.7 <br /> 14A, le ffetic, 0— i'/02 ,0 <br /> A plicant's Mailing A dress <br /> / <br /> igne Dat : CCB# (if applicable) <br /> PP ) <br /> Applicant is the❑Owner El Authorized Representative ❑Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL JULY 2022.DOCX Rev 1/15,3/18,6/22 <br />