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Application for Onsite For City Use only: T ' I/) <br /> ``�� JJJ <br /> —s ¢ City°f J: Wastewater Treatment System OCT 17 2022 <br /> Date Received <br /> MARION COUNTY PUBLIC WORKS Received by MARION COUNTY <br /> BUII,DDIG INSPECTION DIVISION Zoning by BUILDING INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 R ipt# <br /> (503)588-5147 Fax(503)588-7948 rity <br /> www.co.marion.or us/PW/Bnildinp_Inspectioa <br /> A.Property Ownerr�I^nformation <br /> et�t I i.„ec.: `c... (yj),t Ism ? 7 3 <br /> Name Mailing Address City,State,and Zip (Area Co( <br /> B.Legal.Property Description. <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1 3 e:I. T;art ' Q 670.)rr.s` - Oz.. 9 734?_,. <br /> Property Address City State Zip Co <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Waterinfonnation <br /> Existing Facility: Proposed Facility: Water Supply: <br /> Single Family Residence -Single Family Residence 2iPublic Name <br /> i <br /> 3 3 <br /> Number of Bedrooms Number of Bedrooms 0 Private <br /> 0 Other Other Well,Spring,S <br /> D.-Type ofApplication <br /> ❑ Site Evaluation ❑ Renewal Permit ❑Authorization Notice for: <br /> 0 Construction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> J Repair Permit 0 Permit Transfer . 0 The Addition of One or More Bedr <br /> Major 0 Minor 0 Existing System Evaluation ❑ Personal Hardship ' <br /> 0 Alteration Permit 0 Record Review ❑ Temporary Housing <br /> / 0 Major 0 Minor 0 Other 0 Connecting to an Existing System] <br /> (over 5-yrs old) <br /> 0 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,T certify that the information T have famished is correct,and hereby grant Marion County,authorized <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of th <br /> i 1-7.ce> rt`L..5 'S tZ—4Ok 1 . T 7 igel 393 W <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> i <br /> ct <br /> tL(Cl( .A-Lskttl_z CDCZ 973rL.S <br /> Applicant's Mailing Address <br /> 1 -.-..- .---.,-- aig0/2--2-_. 6? 1_t-C3 <br /> ; Date: CCB# (if applicable) <br /> i <br /> i <br />