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6-23—oC)3ZG3—PR.mT <br /> .. Application for Onsite For City Use Only: Date Stamp: <br /> _� Wastewater Treatment System city of —� <br /> Date Received ECVED <br /> MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by APR 20 2023 <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 MARION COUNTY <br /> (503)588-5147 Fax(503)588-7948 Receipt# <br /> www.co.marion.or.us/PW/Buildinglnspection Activity# BUILDING INSPECTION <br /> A Property_Owner Information <br /> Fr cc- Doti I I6 2_5 6 lfLr, s 2 S;l ver'Joy, 0 r )3- 93o-106 7 <br /> Name Mailing Address �J City,State,and Zip (Area Code)Phone# <br /> B P2.7 scnptton �,Leg al De <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 6c-6° L 5:(1(te-i2,de. 17 .. Subbkvii-4 0I2 97:7 5 <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 OPublic <br /> 2_ Name i <br /> Number of Bedrooms Number of Bedrooms [Private VC-' <br /> ❑ Other ❑ Other Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation El Renewal Permit ❑Authorization Notice for: <br /> 1QrConstruction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor 0 Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review El 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 /> Flvw t c- GonSfrvc,4-,'on S03-4S7/-2260 3--11--/r7y <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> (123 s 54: 5c4 h i o k 973 / <br /> Applicant's Mailing Address <br /> _ &f)v il/2OA3 2-3 /-/q2 - <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the❑Owner [ thorized Representative Authorization to Apply form Attached <br /> F:\FORMS\SEPTIC\S-01 ONSITE APPL SEPT 2022.DOCX Rev 1/15,3/18,6/22 <br />