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dq_ tpcouack <br /> r'ls.,,� Application for Onsite <br /> u� '1 For City Use Only: Date Stamp: <br />' —`�` ` Wastewater Treatment System City of <br /> —7—,---I _'' Date Received RECEIVED <br /> I - = MARION COUNTY PUBLIC WORKS Received by <br /> BUILDING INSPECTION DIVISION Zoning by AUG 0 8 2024 <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/PW/BuildinaInsnection. Activity#�s <br /> A.Property Owner Information <br /> `/V--- (7, el= Pjtot eile Col-1-0 _s ivet-- ---4f2J- f 7- .�.W - 9'.S'/-QT 73J" <br /> Name / Mailing Address City,State,and Zip (Area Code)Phone# <br /> B.Legal Property Description <br /> Sits _S g 7-7 s ok I[. <br /> Legal Description Tax Lot <br /> Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> l7_4 O Co -u ../-+vit_ Gr L .S' i/u-•�.rt.� d <br /> i.Property Address , City State 9 Cod 1 <br /> Directions to Property: <br /> a <br /> C.Existing Facility I Proposed Facility/Water Information <br /> Existing Facility: Proposed Facility: Water Supply: <br /> isSingie Family Residence ❑ Single Family Residence ❑Public <br /> 3 Name <br /> Number of Bedrooms Number of Bedrooms ja Private ...t.(/ <br /> ❑ Other ❑ Other <br /> Well,Spring,Shared <br /> D.Type of Application <br /> ❑ Site Evaluation ❑ Renewal Permit <br /> El Construction PermitDAuthorization Notice for: <br /> 0 Permit Reinstatement 0 Replacing a Dwelling <br /> © Repair Permit 0 Permit Transfer <br /> ❑ Major 0Minor 0 ExistingSystem Evaluation 0 The Additionof One or More Bedrooms <br /> El Personal Hardship <br /> dship <br /> ❑ Alteration Permit 0 Record Review <br /> 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <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,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 /> $�n-r ti. (..)-- %. ..904%.._ ...0730t 73 - 7/S 7 17so a <br /> Applicant's Name-Please Print Legibly Applicant's Phone Number DEQ Lic.# (if applicable) <br /> 3--79. " s...L. . ., idol._ s: *Au.. .-- 0 r 5 73a1 <br /> Applicant's Mailing Address <br /> .......A„._........------ &-- 2,9 <br /> Signature Date: ' CCB# (if applicable) <br /> Applicant is the 0 Owner fa Authorized Representative ❑Authorization to Apply form Attached <br />