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. <br /> , ,a q Application for Onsite For(Sty Use Only: Date Stamp: <br /> Wastewater Treatment System City of <br /> Date Received CE <br /> V E "..- <br /> • EN <br /> MARION COUNTY PUBLIC WORKS Received by _ <br /> BUILDING INSPECTION DIVISION Zoning by MAR 04 2022 ---f <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# BUILDING I'1SPEC11ON <br /> www.co.marion.or.us/PWBuildingInspection Activity# <br /> • <br /> -- : -. .. . . .-,A•._Property:OwIner,Infoiniatiori;:,- .,-. . ,. _ .. .. .. _ <br /> VQs01l (or/,/e F2S U/ ,Qr tZ .si /VeriOi t t 1.iato 83 -/4 Sz/r-5 '- 9 '5Z <br /> Name Mailing Address _ City,State,and Zip (Area Code)Phone# <br /> ':B.Legal Pro a Description= '`-; - '' - • <br /> Legal Description Tax Lot Acreage or Lot Size <br /> C'(oilerrkn (e. Sob. (tô1- ) . <br /> Subdivision Name Lo <br /> Block <br /> S�/.:s' C o 'erda le Dr . - ir>i-pmv- Or 9?. Z . <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> ..C.._Existin-'Faci /.Pro os acili VWater-'Informatio •`. .: <br /> Existing Facility: Proposed Facility: Water Supply: <br /> • <br /> ['Single Family Residence ["Single Family Residence DPublic <br /> 4 Name <br /> Number of Bedrooms Number ofBedrooms Private U0 cU,( <br /> 0 Other 0 Other Well,Spring,Shared <br /> - :'D.;Tye'of' . •.; c ,. ",:- <br /> U. Site Evaluation El Renewal Permit <br /> DAnthorization Notice for. <br /> ❑ Construction Permit <br /> ❑ P• ermit Reinstatement El Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ E• xisting System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit 0 R• ecord Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor 0 O• ther ❑ 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 retuned 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 /> D r-e_uo ( 1yr cO3 �tq4 ie365 _8��Applicant's Name—Please Print egibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> PO i_ ot' ZUS ) Fie/zev LI) - • <br /> Applicant's Mailing Address <br /> a..9._, <br /> 4/vzzbzz /6 6 ( _ <br /> Signature Date: <br /> CCB# (if applicable) <br /> Applicant is the 0 Owner El Authorized Representative ❑Authorization to Apply form Attached <br />