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aa_ 6 l <br /> 46-1-41 . Application for Onsite natestam : • <br /> For City Use Only: P <br /> it`:Ol <br /> - • Wastewater Treatment System i 1�L2 6 2022 . <br /> Dare Received --_ _ <br /> • <br /> M.ARiON COUNTY PUBLIC WORKS Rc.:eived by_ MA , ION COUNTY <br /> BUILDING INSPECTION DIVISION Zoning by -. -- BUILD NG INSPECTION <br /> 5155 Silverton Rd NE Fee <br /> Salem OR 97305 <br /> (503).580-5.147 Fax(503)588-7948 Receipt r--- ^-•. <br /> wMw.co:marion.or.us/PWIBuitdinainspeitiot! Activity# <br /> A. Property Owner Information 97 (7 <br /> Melissa Perez 871 Iva Ln NE Salem, OR` 9-. 971-285-7710 <br /> Name `- Mailing Address City,State,and Zip (Area Code)Phone# • _ <br /> B.Legal Property Description • <br /> .91 Acres <br /> Legal Description Tax Lot Acreage or Lot Size <br /> • <br /> Subdivision Name Lot Block a871 Iva Ln NE Salem OR <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 /> • <br /> ®Single Family Residence ❑ Single Famil Residence ❑Public <br /> 4 - Name <br /> Number of Hedrnoms Number of Bedrooms ® Private Well <br /> ❑ Other _ _.._. ❑ Other Well.Spring.Shared • <br /> D.Type of Application <br /> i `i Site Evaluation ❑ Renewal Permit Authorization Notice for: <br /> • Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> • <br /> 91. RcQ r Permit ❑ Permit Transfer 0 The Addition of One or More Bedrooms <br /> • X.Major 0 Minor ❑ Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ._ ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> 0 Other Please Specify <br /> !'the required,/ee and attachments are not included with this application,it will he returned to:ou 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 /> Erin Sharp/E and Z Excavating LLC 971-409-7495 #39104 <br /> Applicant's Name—['tease Print Legibly Applicant's Phone Number DF.Q Lie.# (if applicable) <br /> PO Box 453, Malaita, OR 97038 <br /> • <br /> Applicant's Mailing Address • <br /> 7/25/22 #220602 <br /> Signature %�� Date: CCB- of applicable) <br /> Applicant is the 0 Owner [I Authorized Representative 0 Authorization to Apply form Attached <br />