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Ez <br /> ..,_ Application for Onsite For City Ike Only: EIVED <br /> Wastewater Treatment System City of <br /> illi Date Received <br /> , MARION COUNTY rustic WORKS Received by JUL 3 0 2024 <br /> BUILDING INSPECTION DIVISION Zoning by <br /> 5155 Merton Rd NE Fee <br /> Salem OR 97395 apt# <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.oa/PW/BuOdInvinsnection AdmtY 4 <br /> A.Property Owner Information <br /> 41a h eflk v... )570 CoRD6A1 �D SE 3 a ten, Oi 773/2 ca3-�fa7_S'0Z3 <br /> Name Mailing Address City,State,and Zip (Area Code)Phone# <br /> 082U/05100/WO B.Legal Pro/ , j 3 z <br /> Legal Description Tax Lot Acreage or Lot Size <br /> Subdivision Name Lot Block <br /> 1570 Cordon Ru 5E ett,14,1 cm7 9 7)/7 <br /> Property Address City State Zip Code <br /> Directions to Property: <br /> C.Existing Facility/Proposed Facility/Water Information <br /> lxta g Facility: Proposed Facility: Water Supply: <br /> mgie Family Residence 0 Single 3 Family Residence ❑Pub <br /> Name <br /> Number of Bedrooms Number of Bedrooms LePrivate <br /> ❑ Other 0 Other We pring,Shared <br /> D.Type of Application <br /> 0 S' Evaluation El Renewal Permit ❑Authorization Notice for: <br /> nstruction Permit 0 Permit Reinstatement 0 Replacing a Dwelling <br /> /: Repair Permit_/ al Transfer 0 The Addition of One or More Bedrooms <br /> 0 Major [8'Minar 31 Existing System Evaluation 0 Personal Hardship <br /> ❑ Alteration Permit 0 Record Review 0 Temporary Housing <br /> ❑ Major 0 Minor 0 Other 0 Connecting to an Existing System Never in Use <br /> TiNif i?ePliAcE (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> If the negedred 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 comet,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 /> Te..s5 g:stmin4 god-- 73z-Vial 513Z-3 <br /> Applicant's Name—Please Print Legibl/ Applicant's Phone Number DEQ Lie.# (if applicable) <br /> Ac#;ôvi# Vt'ci ,'ki 1O'a i fmin;r k7 ce SI I1.11 ,i? q731i <br /> Applicant's ailing / <br /> 07 30 Z J: .Zt <br /> Applicant is the❑Owner IB Authorized Representative [ lerization to Apply farm Attached <br /> i <br />